Citizens State Bank
Attn:  Dave Sunlin
PO Box 517
117 West 1st Street
Monticello, IA  52310

You Have the Right to Choose

In this notice, we have explained our policy about the disclosure of certain information.

Affiliates. We have explained the kinds of information we may disclose to our affiliates. We have also explained the kinds of affiliates with whom we may disclose the information. If you prefer that we do not disclose information to our affiliates you may opt out of those disclosures, that is, you may direct us not to make those disclosures (other than the disclosures permitted by law).

Your decision to block the disclosure of your information will apply to information collected from all products and services you receive from us. Remember, though, that your opt out will not apply to information we share that is related to your actual transaction and experience with one of us, which we make available to our affiliates.

If you have obtained one or more products or services jointly, an opt out instruction by any party will be effective for all of that party's information we have collected and for all information collected in conjunction with the product or service for all other joint parties. If one of you chooses to opt out, no information we have collected about you will be shared, nor will we share information about any other joint party collected in conjunction with the product or service. If you previously sent us an opt out, then we will apply your instruction to all the information you can now opt out of as described in this disclosure. If you have joint accounts, your previous opt out will also apply to information about other parties to your accounts as described in this disclosure.

If you wish to opt out of the disclosure of your information, you may do so by checking the appropriate box(es) below and returning this form to us at this address:
Citizens State Bank
Attn:  Dave Sunlin
PO Box 517
117 West 1st Street
Monticello, IA  52310

____Do not share my information, other than information relating to your transactions and experiences with me,
with your affiliates.

Signature_____________________________________________________


Name(s)______________________________________________________


Social Security Number(s)________________________________________


Account Number(s)________________________________________________


Street Address_________________________________________Apt#_______


City, State, ZIP___________________________________________________