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Authorized Agreement for Preauthorized Payments - from other financial institutions

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

Company Name ____Town North Bank___________________ Loan Number ____________________________

I/we hereby authorize Town North Bank, hereinafter called COMPANY, to initiate debit entries and to initiate,
if necessary, credit entries and adjustments for any debit entries in error to my/our (  ) Checking (  ) Savings account
(select one) indicated below at the depository named below, hereinafter called DEPOSITORY, to credit and/or debit the
same to such account.

Depository Name _____________________________________________ Branch _______________________________

City ________________________________________________________ State ________________________________

Routing Number ______________________________________________ Account ______________________________

This authorization is to remain in full force and effect until COMPANY has received written notification from me (or either
of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable
opportunity to act on it.

Name ______________________________________________ Social Security Number __________________________

Signature _________________________________________________________ Date ___________________________

Name ______________________________________________ Social Security Number __________________________

Signature _________________________________________________________ Date ___________________________

Signature _________________________________________________________ Date ___________________________
                                        (If two or more signatures required)

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

                                                          PLEASE ATTACH VOIDED CHECK