Authorization for Direct Deposit

Legal First Name:

Legal Last Name:

Shareholder ID (if known):

Mailing Address:

SSN (Last 4 Digits):

City/State/Zip:

Birth Date:

Email:

Phone (including area code):

Check one:

Initial Enrollment for Direct Deposit
Change Account Information
Cancel Direct Deposit

Complete all information requested below:

Bank or Institute for deposit:

Bank Account Number:

Bank Routing Number (ABA): If you do not know this number contact your financial institute. We cannot process direct deposit without this number.

Check one:
Savings Account
Checking Account

By signing below, I certify to Far West Inc. (FWI) that I am an owner of the bank account listed above. I authorize FWI, as appropriate, to initiate credit entries to this bank account at the Depository listed above. I further authorize FWI to initiate debit entries/adjustments for any credit entries FWI makes in error to this bank account, provided I receive notification with regard to any such debit entries/adjustments. This authority is to remain in full force and effect until FWI has received my written notification of termination in such time and manner as to afford FWI and the above Depository a reasonable opportunity to act on it, unless I fail to keep my address updated with FWI, in which case I understand that direct deposit will be cancelled.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature:

Date:

If you have any questions regarding the completion of this form contact our Anchorage office at (907) 276-2580 Fax number: (907) 276-2581