Authorization for AutoPay Enrollment Form - Citizens Bank

Authorization for AutoPay Enrollment Form Thank you for your interest in the Citizens Bank AutoPay program. AutoPay simplifies your Citizens Bank credit card monthly payment by automatically deducting your payment from your checking or savings account.

How does it work? You never have to worry about missing a payment since we will deduct the payment due on your credit card account from your checking or savings account each month. You have two payment options to choose from:

1) Minimum Payment: The minimum payment due as shown on your current statement. 2) Statement Balance: The balance due as shown on your current statement.

All payments will be debited from your checking or savings account and paid to your credit card account on the payment due date shown on your statement.*

Are there fees for this service? There is no fee for the AutoPay service. However, if we are unable to deduct the payment from your checking or savings account, we may charge a late payment fee.

How do I enroll? Simply complete the form on the third page and mail the completed form back to us.

When will my automatic payments begin? Your first AutoPay deduction will occur within 30 days from the time we receive your AutoPay Enrollment Request Form. You should continue making your credit card payments until you receive written confirmation from Citizens Bank that you have been enrolled in the AutoPay program.

Please see the next page for the Preauthorized Automatic Transfer Agreement before enrolling, please keep a copy of this page for your records. If you have any questions please contact us at the toll free number listed on your statement or on the back of your Citizens Bank credit card.

*If your payment falls on a weekend or holiday, the automatic transfer will occur on the first business day before the due date shown on your statement.

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PLEASE KEEP THIS COPY FOR YOUR RECORDS

AutoPay Enrollment Request Form

? YES, I authorize Citizens Bank to enroll my credit card account in the AutoPay program. I would like the following AutoPay payment option:

? Minimum Payment (Minimum Amount Due on current statement) ? Statement Balance (Balance Due on current statement)

Transfer From: Financial Institution Name: _____________________________________________

Checking ? or Savings* ? Account Number: ______________________________

Routing/Transit Number: _______________________________________________

*If the account you want your payment taken from is a savings or money market account, there may be transaction limits. Please contact your financial institution for information regarding these accounts

Transfer To: Citizens Bank Credit Card Account Number: _______________________________

Cardholder Name: ____________________________________________________

PREAUTHORIZED AUTOMATIC TRANSFER AGREEMENT:

I authorize Citizens Bank to initiate an electronic fund transfer ("automatic transfer") from the checking or savings account ("Account") that I have indicated with my enrollment request to pay my Citizens Bank credit card monthly bill payments. As I selected above, the amount of the automatic transfer from my Account will equal the minimum payment or my statement balance on my credit card account on the date my payment is due.

I understand that Citizens Bank will process my request upon receipt and send me written confirmation as to when the automatic transfers will begin. Until I receive written confirmation from Citizens Bank, I understand that I should continue to make payments. The automatic transfer will be deducted from my Account on the payment due date shown on my statement. I have the right to receive notice of all transfers varying from the monthly payment amount. This authorization will remain in effect until I order my bank to stop payment or until Citizens Bank notifies me that this automatic transfer is no longer in effect. I understand that a stop payment must be received by my bank at least three business days before the transfer to be stopped is scheduled to take place. If I decide to stop payment, I agree to notify Citizens Bank when I do so.

Citizens Bank may cancel this agreement if: (a) the financial institution where I have my Account fails for any reason to honor my Citizens Bank automatic transfer request; (b) my Account has insufficient funds to pay any Citizens Bank automatic transfer request; (c) any other reason deemed sufficient by Citizens Bank. In the event that my financial institution refuses the automatic transfer for any reason, any credit for the payment that Citizens Bank makes to my credit card account will be reversed. If the automatic transfer is refused by my bank for any reason and consequently Citizens Bank does not receive my credit card payment on time, Citizens Bank may also charge my credit account a Late Payment Fee in the amount specified in my Credit Card Agreement, as amended to date. The terms and conditions of my Credit Card Agreement will continue to apply, including applicable Finance Charges.

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PLEASE RETURN THIS FORM TO THE ADDRESS NOTED BELOW

AutoPay Enrollment Request Form

? YES, I authorize Citizens Bank to enroll my credit card account in the AutoPay program. I would like the following AutoPay payment option:

? Minimum Payment (Minimum Amount Due on current statement) ? Statement Balance (Balance Due on current statement)

Transfer From: Financial Institution Name: _____________________________________________

Checking ? or Savings* ? Account Number: ______________________________

Routing/Transit Number: _______________________________________________

*If the account you want your payment taken from is a savings or money market account, there may be transaction limits. Please contact your financial institution for information regarding these accounts

Transfer To: Citizens Bank Credit Card Account Number: _______________________________

Cardholder Name: ____________________________________________________

PREAUTHORIZED AUTOMATIC TRANSFER AGREEMENT:

I authorize Citizens Bank to initiate an electronic fund transfer ("automatic transfer") from the checking or savings account ("Account") that I have indicated with my enrollment request to pay my Citizens Bank credit card monthly bill payments. As I selected above, the amount of the automatic transfer from my Account will equal the minimum payment or my statement balance on my credit card account on the date my payment is due.

I understand that Citizens Bank will process my request upon receipt and send me written confirmation as to when the automatic transfers will begin. Until I receive written confirmation from Citizens Bank, I understand that I should continue to make payments. The automatic transfer will be deducted from my Account on the payment due date shown on my statement. I have the right to receive notice of all transfers varying from the monthly payment amount. This authorization will remain in effect until I order my bank to stop payment or until Citizens Bank notifies me that this automatic transfer is no longer in effect. I understand that a stop payment must be received by my bank at least three business days before the transfer to be stopped is scheduled to take place. If I decide to stop payment, I agree to notify Citizens Bank when I do so.

Citizens Bank may cancel this agreement if: (a) the financial institution where I have my Account fails for any reason to honor my Citizens Bank automatic transfer request; (b) my Account has insufficient funds to pay any Citizens Bank automatic transfer request; (c) any other reason deemed sufficient by Citizens Bank. In the event that my financial institution refuses the automatic transfer for any reason, any credit for the payment that Citizens Bank makes to my credit card account will be reversed. If the automatic transfer is refused by my bank for any reason and consequently Citizens Bank does not receive my credit card payment on time, Citizens Bank may also charge my credit account a Late Payment Fee in the amount specified in my Credit Card Agreement, as amended to date. The terms and conditions of my Credit Card Agreement will continue to apply, including applicable Finance Charges.

______________________________________________________________ Authorized Signature of Checking or Savings Account Holder

Cardholder Name:_____________________________

Return this form to: Citizens Bank P.O. Box 7092 Bridgeport, CT 06601-7092

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Date:____________

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