Authorization Form for Direct Payment to a Loan

Authorization for a Direct Payment to a Loan

Authorization Agreement

I hereby authorize Total Community Credit Union (TCCU) to initiate an automatic debit to my account at the financial institution named below for payment on my loan with TCCU as noted below. Further, I agree not to hold TCCU responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part of my financial institution. I also understand that if the authorized debit is returned to TCCU for any reason, the applicable NSF fee will be assessed against my TCCU account in accordance with the fee schedule in effect at that time. Recurring entries will remain in effect until TCCU receives a written notice of cancellation from me or my financial institution.

Financial Institution Information

Financial Institution *

Routing Number *

Account Number *

Checking

Savings

Transfer Amount ($) *

Date of Transaction *

The ACH payment will be a recurring transaction. Please indicate the day of the month you prefer:

15th of the month

30th of the month

TCCU Account Information

First Name *

Last Name *

Account Number *

Loan Suffix Number *

Signature

Please mail this form for my signature

I will visit the credit union to sign this form

Date

For Cancellation of an ACH Origination:

I wish to cancel the above ACH origination authorization. I understand that this cancellation notice must be given at least 5 days prior to the scheduled transaction date.

Please mail this form for my signature

I will visit the credit union to sign this form

Date

Thank You