Internet Banking Enrollment Form
Yes, I would like to enroll for Internet Banking with Heritage Community Bank.
1. Complete the items by using the tab key.
2. Before submitting the enrollment form, please print a copy.
3. After submitting the enrollment form, please sign and date the form.
4. Then, drop it off at any of our offices or mail the form to:

| Heritage Community Bank Attn: Internet Banking P.O. Box 1458 Danville, KY 40423-1458

First Name or Business Name Middle Initial

Last Name or re-enter Business Name

Mailing Address

Address Line 2

City State ZIP Code

Social Security Number or Tax ID Number (Do NOT include dashes)

Re-enter Social Security Number or Tax ID Number

Daytime Telephone Number

Evening Telephone Number

Date of Birth or Date of Incorporation (mm/dd/yyyy) / /

E-mail Address (Required for the Bill Payment service)

Mother's Maiden Name (for security verification)

Please list the Heritage Community Bank accounts you'd like to activate for Internet Banking:

Account Type | Account Number
Account Type | Account Number

Please specify which transfers you would like us to allow, as well as the specific account numbers using the form below. Any account that requires multiple signatures to authorize withdrawals is not eligible for transfers or Bill Pay. You can set up a maximum of eight transfers.

Hint: If you want to transfer from savings to checking as well as from checking to savings, list both.

FROM Acct. Type | Acct. Number | Maximum Amt. | TO Acct. Type | Acct. Number
|  | $ |  |
|  | $ |  |
|  | $ |  |
|  | $ |  |
|  | $ |  |
|  | $ |  |
|  | $ |  |
|  | $ |  |

FREE Inquiry and Transfer Service -- You may view account information and transfer funds between accounts at No Charge!

UNLIMITED Bill Payment Service -- We are offering unlimited bill payments for an initial setup fee of $9.95. After being approved, you will be charged $5.95 a month for unlimited bill payments. The fees mentioned above will be charged to the account you identified as your designated Heritage Community Bank account for Bill Pay.

Your Designated Heritage Community Bank Account Number for Bill Pay
(a checking account is required for Bill Payment service)

If FREE Inquiry and Transfer Service is selected the undersigned has acknowledged and read the Internet Banking User Agreement and agree to the terms stated on the form. If UNLIMITED Bill Payment Service is selected the undersigned has acknowledged and read the Electronic Bill Payment Services Disclosure and agree to the terms stated on the form.

I understand that my Password must be safeguarded. If this is a business or similar account, I hereby certify that I am authorized by the business or other entity to enter this Agreement, and hereby indemnify Heritage Community Bank for any losses related to claims alleging unauthorized use of the Password.

Signature of Account Owner |  | Date

PLEASE READ BEFORE SUBMITTING

Before you click the submit button, please print and sign your enrollment form.* Return the signed enrollment form to the nearest Heritage Community Bank branch, fax it to (859) 239-9275, or mail it to:

Heritage Community Bank
Attn: Internet Banking
P.O. Box 1458
Danville, KY 40423-1458

Upon receipt of your signed enrollment form we will send you registration instructions by e-mail (or US mail if you do not have an E-mail Address). If you need assistance please call (859) 239-9200 from 9 a.m. - 5:00 p.m. weekdays or e-mail us at mailto:online@hcbmail.com. We'll be happy to assist you.

*Certain browsers may not be capable of printing all of the information. If you find the information you input missing, or you do not have a printer, please click here . We will mail a copy to you for your signature.

Thank you for choosing Heritage Community B@nk's Internet Banking.