Lafayette Community Bank

Community Rewards Program

To enroll in the Community Rewards Program, please print out this page. Mail or bring the completed form to Lafayette Community Bank, PO Box 779, 2 N 4th St, Lafayette, IN 47902. The information you provide should be the same as we have associated with your account at Lafayette Community Bank.

You will not be consider to have enrolled, nor will rewards begin to accrue, until a signed and dated form has been delivered to Lafayette Community Bank.

Phone Number
SSN or EIN
First Name
Last Name
Business Name
Zip Code
E-mail Address
Selected Charity

Date	Signature
Date	Signature

Please initial your choice:
	YES, I give permission for Lafayette Community Bank to provide my name, address, phone number, and reward amount to the school or non-profit organization I have chosen.
	NO, I do not give permission for Lafayette Community Bank to provide my name, address, phone number, and reward amount to the school or non-profit organization I have chosen.