Authorization Agreement For Preauthorized Payments Form printable pdf download

If you want us to automatically debit or draft a deposit account for your loan payment each month, please:

Complete the application form below and mail it with the Required Documents to:

Regions Mortgage-Customer Service, Draft Specialist

P.O. Box 18001

Hattiesburg, MS 39404-8001

OR, Fax the completed form and Required Documents to: ATTN: Draft Specialist at (601) 554-2385,

OR, sign up online at , select the “payments” tab, and follow the instructions there.

You must continue to make your monthly loan payments by other means until the automatic debits begin. You will

be notified in writing of the date when automatic debits will begin.

AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS

Please complete the following:

Loan Number: ________________________________ (10 digits)

Mortgagor(s) Name(s):____________________________________________________________

Home Phone: _______________________________

Work Phone: _______________________________

Name(s) on Deposit Account: _____________________________________________________

Name of Deposit Account Bank: __________________________________________________________

(Signature card required on business accounts.)

ABA or Routing Number: _________________________________________ (must be exactly 9 digits)

Deposit Account Number: ______________________________ Checking ______ or Savings ______

Select one: ____Debit the payment on the due date.

____Debit the payment on the ____ day of the month. (To avoid a late fee, make sure this date is

within your grace period.)

Month you prefer the automatic debits to begin is ___________________

Optional: In addition to the monthly payment, please debit an additional $___________to be applied to principal.

Required Documents:

For Checking - Attach a Voided Check,

For Savings - Attach a Copy of your Account Statement

By signing below:



I authorize Regions Bank to debit the Deposit account identified above for the monthly payment due on the

loan identified above and any additional amount indicated above.



I understand that:

The amount debited monthly will include any changes in the monthly payment resulting from

changes in my escrow items and/or changes under my loan documents and/or changes required by

law.

I AM RESPONSIBLE FOR MAKING THE PAYMENTS DUE ON THE LOAN BY OTHER MEANS IF THE

PAYMENT IS NOT DEBITED BY THE DATE SPECIFIED, NO MATTER WHY THE DEBIT DOES NOT OCCUR.

Automatic debits scheduled on a weekend or holiday will be made on the next business day.

If the loan becomes delinquent, the automatic debit may be discontinued.

If the automatic debit is discontinued, the mortgage payments must be made by other means.

I will be notified if the automatic debit is discontinued.

I will be responsible for any late charges or penalties.

Signature: ______________________________________________

Date: _______________________________________

Signature: ______________________________________________

Date: _______________________________________

Authorization Agreement For Preauthorized Payments Form

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