Welcome to State Bank of Cross Plains

Electronic Statement (eStatement) Enrollment

Please provide all the requested information. When you have completed the form, press the Submit button to send your form to State Bank Cross Plains. All our forms are completely secured. However, if you prefer, you may print this form out and mail or fax it to us. You may also drop it off at one of our convenient locations.

State Bank of Cross Plains
Attn: Account Service
1205 Main Street
Cross Plains, WI 53528
FAX# (608) 798-3591

Please Note: For security purposes, you will receive a phone call from our Account Service department to verify the information in this form. If you have any questions, please contact our Account Service department at 608-798-2400.

New Enrollment:			Cancel Enrollment:
Change Email Address:			Add Accounts:
Personal Information:
Name of Account Owner 1:
Date of Birth - Account Owner 1:
Name of Account Owner 2:
Date of Birth - Account Owner 2:
Daytime Phone Number:
Email Address:
Re-Enter Email Address: (for verification purposes)
Account Information:
Please enroll me (us) to receive the following statements electronically:
Checking	Savings	Account Number:
Checking	Savings	Account Number:
Checking	Savings	Account Number:
Checking	Savings	Account Number:

Please Note: By submitting this form you are certifying under penalties of perjury that you are the above named person within this document, that you are an owner on the account(s) listed above and that the email address listed above is your email address. Enrollment for the electronic statement service requires you to have access to a personal computer, which permits you to access the email account listed above. By completing and clicking on the Submit button below, you are authorizing State Bank of Cross Plains to email you that your statement is ready for you to view on-line. By choosing this, you will not receive paper copies of those statements. If you currently receive your checks back with your statements, you agree to discontinue receiving your physical checks back. All regulations and consumer protection acts applying to paper statements will also apply to statements received via electronic means. After you enroll, you can always terminate your enrollment and stop receiving your statement electronically by notifying State Bank of Cross Plains via this electronic form or by sending notification to the address listed below. There is no fee to cancel your enrollment and you will then begin receiving paper copies of your statements again. If you wish to receive a paper copy of any statement that has been sent to you electronically, you can contact us by calling our Account Service department at 608-798-2400 during normal business hours or by mail by writing to: State Bank of Cross Plains Attn: Account Service 1205 Main St. Cross Plains, WI 53528 You are entitled to receive, upon request, one free paper copy of the statements we email you. You will be charged in accordance with our standard fee schedule for all additional copies.

For Bank Use

Doc Dis Group: _________
Truncate: ______________
Email _________________
Initials: ________________

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Electronic Statement (eStatement) Enrollment

Personal Information:

Account Information: