Ach Debit Authorization/change/cancellation Agreement Form

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ACH DEBIT AUTHORIZATION/CHANGE/CANCELLATION AGREEMENT
New Authorization
Change
Cancellation
Member Name
Member Account Number
Account Type
Member Daytime Phone Number
EXTERNAL INSTITUTION INFORMATION/TRANSACTION DETAILS
Bank or CU Name
Name on Account
Date to Start
Routing Number
Dollar Amount
Account Number
Frequency
Account Type
REQUEST TO STOP PAYMENT
Cancel all Future Transactions:
Stop Payment for the transaction scheduled to occur on this date only:
Stop Payment for the transaction up to and including this date:
Please note:
The Credit Union requires a signed Authorization Agreement five (5) business days prior to the first scheduled
payment.
Terms and Conditions for Changes and Cancellations: This form must be received and acknowledged by the Credit Union at least
ten business days prior to the next scheduled transaction. A fee will apply for each stop or cancellation request. All fees will be
assessed in accordance with the Credit Union’s fee schedule. If The Credit Union is unable to accommodate your stop payment
request, we will not be liable for any penalties or charges assessed at the above named Bank or Credit Union, including the amount of
the ACH debit. If this stop payment request applies to a loan held at The Credit Union, you are still obligated to pay for the loan as
agreed to in your loan application and loan promissory note. You must continue to make the loan payment by other means until the
debt has been repaid in full. If this debit is for a loan payment, I understand that it is my responsibility to notify the credit union to stop
the debit once the loan is paid in full. All requests – change or cancellation must be provided at least five (5) BUSINESS DAYS prior to
the next scheduled debit. If the loan is paid off and the credit union has not received instructions to stop the debit, I understand that
the funds will be credited to my Prime Share Account. I also understand if the debit is scheduled to occur on a non-business day, the
debit may occur the business day prior to ensure posting on the scheduled date.
I am an authorized signer, or otherwise have authority to act, on the account identified in this statement. I agree to the Terms
and Conditions listed above for ACH Origination Cancellation. Please stop payment for ACH transactions originated through
The Credit Union using the instructions provided above. New ACH authorizations, the Credit Union must have a signed form
5 business days prior to the first scheduled payment
Name (Print)__________________________
Signature___________________________
Date__________
Please attach a voided check, loan payment coupon, or account statement for verification purposes.
For Credit Union Use Only
Form completed by: ________________________________________
Branch _________
Date_______________
ACH Department:
Initials___________ Date___________

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