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Preauthorized Funds Transfer Request

Please print this application, fill in the information requested below, sign it, and mail to the referenced address below.

Town North Bank
P.O. Box 814810
Dallas, TX 75381-4810
Attn: Loan Servicing

Effective date  __________________________________

On the ___________________________________ day of each month, charge my

Account number______________________________ in the amount of $ ________________________________________

and credit this amount to the following:

Account number _____________________________________________________________________________________

Signature________________________________________________________________Date_______________________

Signature________________________________________________________________Date_______________________
                                            (If two or more signatures required)

Mailing Address _____________________________________________________________________________________

City __________________________________________ State __________________________ Zip __________________

Daytime Telephone Number (______) ____________________Evening Telephone Number (______) _________________