Debit Card / ATM Overdraft Opt-In Form

* indicates a required field

*Name

*Address

*City, State Zip Code

	*Account Number		*Account Name
	Account Number		Account Name
	Account Number		Account Name
	Account Number		Account Name
	Account Number		Account Name
	Account Number		Account Name
	Account Number		Account Name
	Account Number		Account Name

*Phone Number - Daytime

Phone Number - Evening

*Email Address

I authorize Midland States Bank to pay overdrafts on ATM and every day debit card transactions. I understand that I have the right to revoke the consent at anytime.

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* indicates a required field