Opt-In Request Form

I Do want First State Bank to authorize and pay overdrafts on my ATM and everyday Debit Card Transactions. *
I Do Not want First State Bank to authorize and pay overdrafts on my ATM and everyday Debit Card Transactions.
(selection required)

Printed Name: (required)

Date:

Account Number:  (required)

* New Program participants are subject to OOPS!TM program qualifications and Bank approval prior to Opt-In (see OOPS!^TM policy)