Identity Theft Joint Account Enrollment

Subscriber #1 Information

First Name

Last Name

Address

City

State

Zip

Home Phone

Work Phone

Cell Phone

Email

Subscriber #2 Information

First Name

Last Name

Address

City

State

Zip

Home Phone

Work Phone

Cell Phone

Email

Subscriber Identification

Account #

Last 4 digits of Subscriber #1 SSN

Last 4 digits of Subscriber #2 SSN

Service Requested

ID Protect Plus (Joint Account Coverage) - $12.95 monthly

ID Protect (Joint Account Coverage) - $7.95 monthly

ID Restoration (Joint Account Coverage) - $6.95 monthly

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Employee Referred by (if applicable):

Agreement & Signature

I choose to enroll in the Deluxe Provent service package selected above and authorize the monthly fee to be automatically deducted from my checking account listed above. I authorize Farmers State Bank to provide limited personal information to Deluxe Provent in order for me to receive the benefits of this service package. I understand that I will be receiving email communications from Deluxe Provent regarding my service. I understand to fully receive full benefits of my service package selected above, I am required to activate my online dashboard as provided to me in an enrollment email. If at any time I wish to cancel this service, I will provide notification to the bank either in person, by phone or through an online cancellation form. By initialing this agreement, I authorize a Farmers State Bank representative to activate the service I have selected above and for the monthly fee to be automatically deducted from my Farmers State Bank account.

Subscriber #1 Initials

Subscriber #2 Initials