Njclass Ach Automatic Debit Authorization

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NJCLASS ACH AUTOMATIC DEBIT AUTHORIZATION
Instructions:
Complete the Automatic Debit Authorization Form below and make a copy of the completed authorization
form for your records. If you are using a checking account for Automatic Debit, you must send a voided check
from that account. If you are using a savings account, you must enclose a savings deposit ticket, which includes
your account number.
MAIL THIS PAGE AND VOIDED CHECK OR SAVINGS DEPOSIT TICKET TO:
NJCLASS
PO BOX 544
TRENTON, NEW JERSEY 08625-0544
Automatic Debit Authorization
I authorize Higher Education Student Assistance Authority (HESAA) and its successors and assigns to initiate
electronic debit entries to my checking or savings account indicated below and I authorize the financial institution
(“BANK”) named below to debit these entries from my account. This authority shall remain in effect until HESAA
and BANK have received notification from me of its termination in such time and in such manner as to afford
HESAA and BANK a reasonable opportunity to act on it, or until my loan account has been paid in full, or until
HESAA or BANK has sent me ten (10) days’ written notice of HESAA’s or BANK’s termination. If I choose to
terminate this authorization to debit my account, I will notify BANK in accordance with my agreement with BANK.
The required monthly payment can change due to new loans, future disbursements of current loans and current loans
reverting to repayment. If the required payment changes for any reason, this authorization will be automatically
amended to authorize the debit of an amount equal to the new required payment plus any optional additional amount
indicated below.
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Draft On: (Check One or HESAA will Select)
7
14
21
28
Optional: In addition to my regular payment, please deduct an additional $_________each month.
NJClass Billing Account Number: ________-______-________NJC________-______-________
(Borrower SSN)
(Student SSN)
Bank Account Holder Name________________________________________ SSN_________-_____-__________
(Please Print Name)
(Social Security Number)
Student Name _________________________________________________________________________________
--
Bank Name __________________________________________City/State ________________________________
Bank ABA # _________________________________________Bank Phone #:_(____)______-_________x_____
Bank Account#:________________________________
Bank Account Type:
Checking
Savings
Bank Account Holder Signature:_________________________________________ Date:____________________
Bank Account Joint Holder Signature:____________________________________ Date:____________________
Please continue making payments by check until you have been notified that this
authorization has been processed. Your current bill statement indicates the payment amount
due.

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