Authorization for Direct Deposit

Legal First Name:

Please enter your legal first name.

Legal Last Name:

Please enter your legal last name.

Shareholder ID (if known):

Mailing Address:

Please enter a mailing address.

SSN (Last 4 Digits):

Please enter the last 4 digits of your SSN only.

City/State/Zip:

Please enter your city, state and ZIP.

Birth Date:

Please enter a valid birth date.

Email:

Please enter a valid email address.

Phone (including area code):

Please enter a 10-digit phone number, including area code.

Check one:

Initial Enrollment for Direct Deposit
Change Account Information
Cancel Direct Deposit

Please choose one option.

Complete all information requested below:

Bank or Institute for deposit:

Please enter your bank or financial institution.

Bank Account Number:

Please enter a valid bank account number (4 to 17 digits).

Bank Routing Number (ABA):

A routing number is exactly 9 digits.

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

Please choose checking or savings.

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:

Please type your name as your signature.

Date:

Please enter the date you signed.

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