DIRECT DEPOSIT CHANGE NOTICE.

CONTACT

Name: Date:

SSN:

Account Number:

Name of company or agent:

Street: City: State: ZIP:

PREVIOUS FINANCIAL INSTITUTION

Name of institution:

Account Number:

Street: City: State: ZIP:

NEW FINANCIAL INSTITUTION |

4200 East Beltline Avenue, Grand Rapids, MI 49525 | IndependentBank.com | 800.355.0641

I hereby authorize you to re-direct future automated direct deposits to my new checking account

Effective Date:

Name (print):

Checking Account Number: Routing Number: 072402652

Signature: Date:

DIRECT DEPOSIT

CHANGE NOTICE.

Give this form to your employer to change your direct

deposit to your new Independent Bank account.

QUESTIONS? Visit IndependentBank.com or contact Customer Service 800.355.0641

You may manually or digitally ﬁll out and sign this form. Some institutions may require a hand signature.