E-Statement Service Enrollment Form
Please Print the form, complete it, sign it, and return it to your local South Louisiana Bank branch or fax it to us at 985-879-3095.

In order to enroll in South Louisiana Bank’s E-Statement Service:

• You must provide us with your valid, working email address;
• You have the capability to accept email notices sent to you by the bank when your statement is ready to view;
• You agree to accept electronic periodic statements in lieu of paper statements; and you are currently enrolled as a user of our internet banking system.

Statements and disclosures will be available through our internet banking system under the heading “E-Statements” for your viewing up to 120 days following when it was first made available to you. After this time, should you need a copy of your statement, you may request a paper copy from
South Louisiana Bank by contacting the electronic banking department at 985-851-3434.

Account Owner(s):

Access ID: Email Address:

Specific account numbers to Enroll:

By signing this document, I acknowledge that I have read and agree to the terms and conditions of the South Louisiana Bank E-Statement Agreement and Disclosure, as made available to me via the South Louisiana Bank Website or given to me in paper form by South Louisiana Bank. I agree to and request that I receive my South Louisiana Bank account statement via the electronic statement “E-Statement” Service for my account(s) as described above. I also agree to allow South Louisiana Bank to add any accounts listed above not already assigned to the access id above. I further authorize South Louisiana Bank to no longer send me a paper statement for my accounts as described above. I also agree to have any and all regulatory information or notices regarding my account, sent to me electronically (if available). I certify that I am an owner for the accounts listed above. I understand that at any time I may cancel my consent to E-Statements as stated in the E-Statements Agreement and Disclosure.

South Louisiana Bank E-Statement and Disclosures: Agreement and Disclosure

Signature:____________________________________ Date:__________________

Bank Use Only:

Signature Verified By:	Date:	Set Up Image Center:	Date:
Reviewed By:	Date:	Set Up Premier:	Date: