Automatic Payment Request Form

Existing Automatic Payment Information

Company Name

Your Company Account Number

Previous Debited Amount

Previous Financial Institution Name

Previous Financial institution Routing #

Previous Financial institution Account #

Your Information

Your Name

Your Social Security Number

Your Address

City

State

Zip Code

Your Home Phone Number

Your Cell Phone Number

Please automatically debit my:

(Ex. Insurance, Vehicle, Public Service, Telephone, etc. as instructed below.)

Westbury Online, SSB

Routing Number: 900082728

Checking Account Number (10 digits):

Savings Account Number (10 digits):

Today's Date:

Effective immediately, I hereby authorize the above named company to automatically debit my TCB account for payment as indicated above. This request is to replace any previous automatic payment authorization and will remain in effect until I change it in writing. If this form is not sufficient for Automatic Payment authorization, please forward the correct form to me for my signature.

Signature:

Today's Date:

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