Teller #
ACH Credit Authorization
I (we) hereby authorize MidWest America Federal Credit Union, hereinafter called COMPANY, to initiate credit entries for deposit to my (our) account
indicated below and the financial institution named below, hereinafter call FINANCIAL INSTITUTION, to credit the same to such account. I (we)
acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law.
Name on Account to Credit ______________________________
Financial Institution receiving deposit _______________________
Start Date _______________ Amount $ ___________________
Account # to Credit ________________ Phone # _____________
Type of Account
: o Savings o Checking o Loan
Financial Institution Routing Transit Number
_______________ (9-digits)
____ ____ ____ ____ ____ ____ ____ ____ ____
Frequency
: o Weekly o Biweekly o Monthly
Please CANCEL my automatic:
loan payment or
deposit for the amount of $ ___________
o
o
as of [date] _______________ with [financial institution’s name] _________________________________________
This authorization is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination
in such time and manner as to afford COMPANY and FINANCIAL INSTITUTION a reasonable opportunity to act on it. If the item, in the above
authorization, would be returned to MidWest America Federal Credit Union, (for any reason other than stop payment) the normal NSF fee will apply.
Likewise, MidWest America reserves the right to cancel the above authorization, if the attempt to perform the above transaction, causes excessive
derogatory conditions. Please allow at least 30 days following prenotification before the item will be disbursed.
____________________________________ Signature ____________________________________________
Print Individual Name
_____________________________ Share ID ________________ Date ___________________
MidWest America Account Number
Please mail the original copy of this form along with a copy of your VOIDED check to:
ACH DEPARTMENT | MIDWEST AMERICA FCU | 1104 MEDICAL PARK DRIVE | FORT WAYNE, IN 46825
If you have any questions, please call 800-348-4738 ext. 4100.
o Approved o Denied Manager’s Signature ______________________________________ Date _________
FORM 10041 (03/13)