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EXHIBIT 99.4
Direct Deposit of Dividends
(Option available to shareholders not electing automatic dividend reinvestment)
We are pleased to offer you the option of having your dividends deposited
directly into the checking or savings account of your choice. By electing to
participate in our direct deposit program, your quarterly dividend payment will
be electronically credited to your account the same day that dividends are paid,
without any further action required on your part. In addition, you will no
longer need to worry about lost, stolen or destroyed dividend checks. The
direct deposit of your dividend will be shown on your regular statement from
your financial institution.
To take advantage of this feature, please complete the bottom portion of this
form and return it to Crescent Bank and Trust Company, Attention: Shareholder
Services. You must enclose a voided check (for checking account deposits) or a
deposit slip (for savings account deposits) along with the completed
authorization portion of this form.
Direct Deposit Authorization
I (we) authorize Crescent Banking Company to initiate credit entries and to
initiate, if necessary, adjustments for any credit entries in error from my
(our) account. I (we) also authorize the financial institution named below to
credit and/or debit adjustments to such account. This authorization will remain
in effect until I (we) give written notice to terminate it.
Please note that everyone on the shareholder account must sign this
authorization, in the same capacity as on the shareholder account. If name(s)
on the shareholder account differ from the name(s) on the bank account, a
medallion guarantee is required.
Financial Institution Information:
(Must be a member of the Automated Clearing House - ACH - Network)
________________________________________________________________________________
Name, Address and Phone Number of Bank
__________________________________ ______________________________________
Bank Account Number Bank Transit Routing Number
[ ] Checking (Contact your bank for this information)
[ ] Savings
Signatures:
__________________________________ ______________________________________
Stockholder Signature Stockholder Signature
________________________ ___________________________ _____________________
Social Security Number Shareholder Account Number Date
________________________________
Telephone Number
