Prearranged Payment Program Authorization Agreement Template printable pdf download

ACH PREARRANGED PAYMENT PROGRAM AUTHORIZATION AGREEMENT

If you would like to authorize Vanderbilt University to deduct your monthly student loan payments from

your checking account by automatic deduction, please:

•

Complete the form below. If your checking account is a joint account, both account holders must sign

the form;

•

Attach a voided, unsigned check to the form;

•

Return the original form and the voided check to the Vanderbilt University Office of Student Loans;

We will process your account for automatic deduction as soon as possible after we receive your form. The

authorization form must reach our office by the 20th of the current month to begin your automatic

payment for the following month. Therefore, if you receive any additional loan statements after sending in

this form, please call our office before sending the payment shown on the statement.

I / we hereby authorize Vanderbilt University to initiate debit entries to my / our account in the entity

institution named below, and I / we authorize the institution to accept and to debit the amount of such

entries to my / our account. Each debit shall be made on the 3rd business day of each month in an

amount equal to my student loan payment.

Name of Institution ___________________________________________________________________

Institution Address ___________________________________________________________________

City _______________________________________

State __________

Zip ________________

___________________________________________

____________________________________

Transit/ABA Number

Account Number

(first nine digits encoded on your check)

This authorization is to remain in full force and affect until all amounts payable to Vanderbilt University for

my student loan(s) are paid in full or until I revoke the agreement as hereinafter provided. Any revocation

shall not be effective until Vanderbilt University has received written notification from me of my desire to

terminate this agreement in such time and in such manner as to give Vanderbilt University a reasonable

opportunity to act on it. I understand that I will be notified of my payment charges debited to my account.

Vanderbilt University reserves the right to cancel my participation at any time.

Borrower’s Name _______________________________

Social Security # ___________________

Borrower’s Email Address ____________________________________________________________

Bank Account Holder’s Name (please print) ______________________________________________

Joint Account Holder’s Name (please print) ______________________________________________

Holder’s Signature ____________________________________________

Date _______________

Joint Account Holder’s Signature _________________________________

Date _______________

Amount of Draft (if not regular monthly payment amount) $ ___________________

Prearranged Payment Program Authorization Agreement Template