Ach Debit Authorization Form printable pdf download

Ach Debit Authorization Form

ACH Debit Authorization Form

The purpose of this form is to authorize the Credit Union to debit your account at another financial institution, on a recurring basis (not for

one-time payments), in order to repay a loan with the Credit Union.

Please note: This form must be submitted at least three (3) business days prior to the desired payment date.

Member Information

Member Name

CU Member Number

Daytime Phone

Cell Phone

Member Email Address

Authorize Coca-Cola Federal Credit Union to initiate a charge to my (choose one):

Effective Date



Checking Account

Savings Account

Loan

Loan Number

Payment Frequency

Dollar Amount

Check One



New Request

Change

Financial Institution being debited

Name of Financial Institution

Institution City

Institution State

Financial Institution 9 Digit Rounting Transit Number

Account Number to Debit

I hereby authorize Coca-Cola Federal Credit Union (CCFCU) to initiate a charge (debit) entry at the Financial Institution indicated above, and

initiate adjustments (if necessary) for any transactions debited in error. I acknowledge that the origination of ACH transactions to my account

must comply with the provisions of U.S. law. This authority will remain in effect until CCFCU is notified by me in writing to cancel it in such

time as to afford CCFCU and the Financial Institution a reasonable opportunity to act on it.

I understand that if the funds are not available in my account on the designated debit date I will be charged an NSF fee. See Rate and Fee

Schedule for fee and details.

Please attach a copy of a voided check and fax to 404-598-2586 or mail to the address below attention Member Services.

Coca-Cola Federal Credit Union

P.O. Box 1734

Atlanta, GA 30301-1734

Coca-Cola Federal Credit Union has the right to terminate, suspend, or audit compliance with agreement and rules, and address restrictions

on ACH origination activity.

Member Signature

Date

ACH Debit Authorization Form • Page 1 of 1

Form # 03-13-815

Ach Debit Authorization Form

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