Fillable Automatic Payment Authorization Form

Automa c Payment Authoriza on Form

Use this form to schedule recurring a recurring monthly transfer from your USPS FCU account or your

account at another ﬁnancial ins tu on to your loan at U. S. Postal Service FCU.

If you are establishing a recurring monthly transfer from another ﬁnancial ins tu on a ach a voided

check from your other ﬁnancial ins tu on when you return this form.

Your Name:

Day me Telephone Number: Extension:

Cell Number: Email:

Apply the transfer to my USPSFCU Account Number _____________________ Loan Suﬃx Number _______

(Note: Automa c payments to a USPS FCU line‐of‐credit cannot be paid from another ﬁnancial ins tu on.)

Select a day of the month for the monthly withdrawal. (Example: 1st, 10th, 15th day) ____________ day

Date of ﬁrst withdrawal (mm/dd/yy) ______/______/____________ Amount: $______________________

WITHDRAW PAYMENT FUNDS FROM (choose one):

 USPS FCU Account _________________________ Savings Checking

 Another Financial Ins tu on: __________________________________________________________

Ins tu on Address:

Ins tu on Telephone Number:

Name as it appears on this account:

ABA Rou ng Number* ___ ___ ___ ___ ___ ___ ___ ___ ___

* The ABA Rou ng Number is the ﬁrst nine (9) digits listed at the bo om of your check. Please a ach a

voided check to this form so we may verify the ABA Rou ng Number.

Account Number __________________________ Savings Checking

I authorize U. S. Postal Service FCU to regularly withdraw funds from my account at the ﬁnancial ins ‐

tu on indicated above to be applied to my loan at U. S. Postal Service FCU indicated above. I under‐

stand that if the scheduled withdrawal date falls on a weekend or holiday the withdrawal will be

made on the last business day prior to the weekend or holiday.

I understand that this process will con nue un l the Credit Union has received wri en no ﬁca on

from me to cancel this transac on. Changes or termina on must be in wri ng and delivered to the

Credit Union no later than three (3) business days prior to the next withdrawal date. The Credit Union

has the right to make appropriate adjustments to my Credit Union account indicated above and has

the right to revoke this agreement at any me.

Signature: ____________________________________ Date (mm/dd/yyyy): _____/_____/_________

Date Received: ________________________________________________

By: _____________________________________________________________________

Please forward to Accoun ng/ACH.

Revised July 2014

Automatic Payment Authorization Form - Usps