Ach Debit Authorization - Credit To Lgeccu - Lge Community Credit Union

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Accounting Fax: 770-420-3850
ACH Debit Authorization
Member Number: ________________
(Credit to LGEccu)
(Rev 12/13)
OFFICIAL USE ONLY
REQUEST RECEIVED: ____ In Person ____By Mail ____By Fax
Date___________ Teller No. _________
Routing and Account number verified
Start ACH Request
Cancel ACH Request
Request Must be Completed & Signed by Member (Please Print)
Authorization Agreement To Request Electronic Funds Transfers
From Another Financial Institution To LGE Community Credit Union (ACH Debits)
I (we) hereby authorize LGE Community Credit Union (LGEccu), to initiate debit entries from my (our) account indicated
below at the depository financial institution named below, hereafter called DEPOSITORY, and to debit 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.
Financial Institution Name _________________________________________________________________________
Financial Institution City & State_____________________________________________________________________
9-Digit Routing Number ___________________
Account Number _____________________________________
Account Type:
Checking
Savings
Name On Account At Other Financial Institution ________________________________________________________
Start Date __________________
(Allow minimum of 5 days for debit to begin. Your account will be debited on or after this date)
Amount: $____________________
Frequency:
Weekly
Bi-Weekly
Semi-Monthly
Monthly
Quarterly
This is a one time request
Credit my LGEccu account number _________________ Share/Loan ID _______ to make this transfer.
This authorization is to remain in full force and effect until LGEccu has received written notification from me (or
either of us) of its termination in such time and in such manner as to afford LGEccu and DEPOSITORY a
reasonable opportunity to act on it. Fees may be charged for any returned item in accordance with our Service
Charge Schedule. Your rights and responsibilities under the law are outlined in the Federal Reserve Board’s
Regulation E that was provided in your account opening disclosures. I hereby agree to indemnify and hold
harmless LGE Community Credit Union from and against all claims that may arise against it by reason of acting
pursuant to the foregoing authorization agreement. I hereby affirm that this information is correct.
Name (s) __________________________________
Driver’s License or other ID # ____________________________
(Please Print)
Signature _______________________________________________________________Date______________________
Daytime Telephone Number __________________________________
Processing Use Only
Processed By: ____________________________
Date: _________________________
Verified By: ______________________________
PLEASE SEND ORIGINAL TO ACH DEPT
You may present your request for this authorization, in person, at any LGEccu office, or you may mail this form to:
LGE Community Credit Union, ACH Dept, 430 Commerce Park Drive, Marietta, GA 30060
You may also fax this form to the Accounting Department at 770-420-3850

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