Authorization Agreement For Ach Direct Deposits Ach Origination Form
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Member Name _____________________________
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Account #
______________
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(including suffix)
I (we) hereby authorize Alabama Credit Union to initiate credit entries to my (our):
Savings Account __________________
Checking Account_________________
Loan Account ____________________
from the financial institution listed below and deposit the funds into the account at Alabama Credit
Union. I (we) acknowledge that the origination of ACH transactions to my (our) account must
comply with the provisions of U.S. laws.
Financial Institution to debit funds from:
Bank/Credit Union __________________________________________________
City/State __________________________________
You MUST provide a
copy of a voided
Routing Number _____________________________
check or a current
bank statement
Account Number _____________________________
showing that you
are an authorized
signer on the
Amount of the transfer $_______________________
debited account.
Date to begin entries _________________________
Day of month the credit is to occur _______________
This authorization is to remain in full force and effect until Alabama Credit Union has received written
notification from me (or a joint owner of the account) of its termination in such a time and in such a manner
as to afford Alabama Credit Union and the Financial Institution a reasonable opportunity to act on it.
NOTICE: You MUST notify Alabama Credit Union in writing if you wish to cancel this
authorization as stated above.
Member’s Signature ________________________________________ Date ______________
For CANCELLATION of an ACH Origination:
I, __________________________________, wish to cancel the above ACH origination
authorization as of (date) _________________________. I understand that this
cancellation notice must be given atleast 5 days prior to the scheduled date of the
transaction.
Member’s Signature ________________________________________ Date ______________
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