Model Form A-9

A-9 Model Consent Form for Overdraft Services

EXPLANATION OF OVERDRAFT COVERAGE

Your Right to Request Overdraft Coverage
We will not pay your overdrafts for ATM withdrawals and debit card purchases you make at a
store, online, or by telephone, unless you tell us you want overdraft coverage for these transactions.
Even if you do not request overdraft coverage for ATM withdrawals and debit card purchases, we
may still pay your overdrafts for other types of transactions, including checks.
Having overdraft coverage does not guarantee that we will pay your overdrafts. If we decide to pay an
overdraft, you will be charged fees as described below.
Overdraft coverage differs from other overdraft services we offer, such as linking your account to another
account with us or an overdraft line of credit. See below for more information, including how to contact
us if you want overdraft coverage to apply to your ATM withdrawals and debit card purchases.
Overdraft Fees
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We will charge you a fee of [up to] [$__] each time we pay an overdraft.

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We will also charge you a fee of [$__] for each day your account remains overdrawn.

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[There is no limit on the daily fees we can charge you for overdrawing your account.]

Other Ways We Can Cover Your Overdrafts
We offer other ways of covering your overdrafts that may be less expensive, such as linking your account
to another account with us or an overdraft line of credit. Contact us to learn more about these options.
How to Request Overdraft Coverage or Get More Information
To request overdraft coverage for your ATM withdrawals and debit card purchases, or for information
about other alternatives we offer for covering overdrafts, please:
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
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Contact us at 1-8xx-xxx-xxxx.
Contact us at [insert Internet address].
Complete the form below and mail it to [insert address].

-------------------------------------------------------------___ I want overdraft coverage for my ATM withdrawals and debit card purchases.
Printed Name: _________________________

Date: _________________________

Account Number: _________________________