Automatic Transfer Authorization Form

Enter your information on this form and print two copies. However, we suggest that you only enter account
number on your printed copies. Provide one copy to Forest Bluff Financial Services and keep the other copy
for your records.

Your Information	Forest Bluff Financial Services Information
Name	Forest Bluff Financial Services 123 Central Avenue Lake Bluff, IL 60044 Contact: Phone:
Address
City
State Zip Code
Phone

Transfer Information

Frequency Monthly Weekly

Effective Date (mm/dd/yyyy) Termination Date (mm/dd/yyyy)

Account Funds are to Transferred From	Account Funds are to Transferred Into
Account Owner's Name	Account Owner's Name
Account Type Checking Savings Other (describe)	Account Type Checking Savings IRA Other (describe)
Account Number (enter after printing) #	Account Number (enter after printing) #
Amount to be Transfered $
Any Special Instructions

This authorization will remain in effect unit I/we give written notice to change it. This authorization may be terminated
by providing 15 days written notice.

______________________________________________	_________________
Signature	Date
______________________________________________	_________________
Signature	Date

Print two copies, enter your account numbers, give one to Forest Bluff Finanical Services and keep one for your records.