eStatement Enrollment Request

*First Name:

MI: *Last Name:

*State: *Zip:

*Social Security Number:

Please complete, print and mail this form to enroll in eStatements to:
Brown County State Bank
E-Statements
101 Main Street
Mt. Sterling, IL 62353

If you have any questions please email bcsb@bcsb.com or call (217)773-3327.

I(we) wish to receive my(our) bank statement(s) electronically via secure e-mail:

* field is required

Primary Account Owner

Joint Account Owner

Please Note: If you have a joint account, both enrollees must be authorized per account to receive eStatements, otherwise, a separate enrollment form may be necessary

First Name:		MI: Last Name:
Social Security Number:		Phone:

Password Selection

You may choose your own password or elect to have one assigned. eStatement passwords are case-sensitive and must be at or between four(4) and eight(8) alpha/numeric characters.

Password:

Leave this field blank if you would like us to assign one for you.

Account Information

Please list all account numbers you wish to access You may also elect to have each statement sent to different/more than one email address. (Please enter information for at least one account.)

Account Number	Type of Account	Email Address(es) to Receive eStatements

Authorization

I (we) have provided Brown County State Bank the above stated information to enroll in eStatement services. I(we) understand that all further banking statements on the above stated accounts will be delivered electronically through secure email, and that is is my(our) responsibility to notify the Bank of any changes to my(our) email address(es). I acknowledge that these eStatements may be emailed on a different date than I have been accustomed to with any existing paper statements.

Before printing, please review for accuracy and print an extra copy for your records.

Signature: __________________________________________

Joint Acct. Owner: ________________________________________