First Community Bank of Crawford

Account Owner(s)					Social Security No. or Tax ID				Date
Address		City					State			ZIP
Phone Number					Mobile Phone Number
Account Number (to receive eStatements)			Account Type (please circle) Checking Savings			Please circle one: eStatement Only (no charge) Continue Paper Statements($2.00/mo)
Email Address				Password (Suggested 6 characters, 1 lower case, 1 upper case, 1 number)
For Internal Use Only
Approving Banker	EO __________ PO__________							Date Added

Upon receipt of your consent, we will provide periodic statements to you on a monthly or quarterly basis, as applicable, to a working email address that you have

provided to us. You will be required to use a password to view the electronic statement. It is your sole responsibility to protect your password from unauthorized persons.

You agree that it is your responsibility to ensure that the electronic statements cannot be intercepted or viewed by others. You understand that you have no expectation

of privacy if the statements are transmitted to an email address owned by your employer. You further agree to release First Community Bank of Crawford County from any

liability if the information is intercepted or viewed by unauthorized parties at your employer or other email addresses selected by you.

By accepting the terms of this agreement, you hereby authorize First Community Bank of Crawford County to provide periodic account statements to you by electronic mail.

Your authorization means that we can provide you with periodic statements of your account electronically to a working email address provided by you. This service is free

unless you elect to continue receiving paper statements, in which case, a monthly fee of $2.00 will apply. You are responsible for notifying us of any email address

changes. Notification of any email changes should be received at least ten (10) business days before the end of your normal statement cycle. You must notify us in writing

of any email address changes. If your electronic mail is returned as undeliverable, an attempt will be made to contact you. If contact cannot be made, a paper copy of

your statement will be sent by U.S. mail and an "Undeliverable Statement" fee in accordance with the most recent fee schedule applicable to your account will appear on your

You have the right to withdraw your consent to receive electronic periodic statements at any time. To withdraw your consent to receive electronic statements, you

must notify us in writing to our Electronic Banking Department, 2925 Alma Hwy, Suite A, Van Buren, AR 72956. The withdrawal of your consent should be received at least

All electronic statements shall be in full compliance with applicable laws and regulations. The provisions in this agreement are part of (and in supplement to) First Community

Bank of Crawford County's Terms and Conditions for Deposit Accounts and are subject to all the provisions in the Terms and Conditions for Deposit Accounts. Each First

Community Bank of Crawford County account that you designate to be included within the eStatement service and eStatements program is also governed by the terms and

conditions otherwise applicable to that kind of account as separately disclosed to you, either in the Terms and Conditions for Deposit Accounts, applications and enrollment

forms, the applicable personal or business fee schedules, credit or deposit agreements, our Privacy Policy or other written disclosures.

I have read and agree to the terms of the Email Statement Disclosure and I would like to receive eStatement delivery for the account listed above.

Authorized Signature on Account:________________________________________________