Print or Type Last Name: ________________________________

Please Print Out, Complete and Sign This Form
Then FAX, Mail or Bring to Any HNB Office

FAX to 570-251-9519
Mail to the HNB Data Processing Department
PO Box 350, Honesdale PA 18431

HNB XPRESS BANKER
Funds Transfer Authorization Request

I/We authorize and direct The Honesdale National Bank to permit funds transfers on HNB’s Xpress Banker Telephone Banking Service between the following accounts, effective today.

I/We understand that a maximum of twelve (12) accounts may be listed.

Accounts to be accessed for Funds Transfers:

__________________________ __________________________

__________________________ __________________________

__________________________ __________________________

__________________________ __________________________

__________________________ __________________________

__________________________ __________________________

___________________________________
Signature of Authorized Signer

___________________________________
Printed Name of Signer and Date

___________________________________
Signature of Additional Authorized Signer (If applicable)

___________________________________
Printed Name of Additional Signer and Date

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For Bank Use Only

Date Received: _______________ Received By: __________

Date Input: __________ Input By: __________

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Rev. 0706