Automatic Payment Request Form - Paper City Savings Association printable pdf download

Automatic Payment Request Form - Paper City Savings Association

AUTOMATIC PAYMENT REQUEST FORM

Print and complete this form to request the transfer of an automatic payment. Each company or

organization which you have arranged automatic payment must be provided with this form.

Please allow sufficient time for your first automatic payment to be activated.

Date: __________________________

Company name:________________________________________________________

Account number: _______________________________________________________

Your information:

______________________________________________________________________________

Name

______________________________________________________________________________

Address

______________________________________________________________________________

City, State, ZIP

______________________________________________________________________________

Home phone

Work phone

I am requesting that my payment be automatically deducted from my account with:

Paper City Savings Association

PO Box 339

Wisconsin Rapids WI 54495-0339

Account number _______________________________________

Routing number ________275971498______________________

Date or Frequency of Payment____________________________

Amount ________________

Please discontinue payments automatically deducted from the account I have closed at:

______________________________________________________________________________

Previous Financial Institution Name

______________________________________________

Account Number

If you have any questions regarding this request, please contact me by mail or call me at the phone

number listed above. If this form is not sufficient for automatic payments, please forward the

authorized company form for my signature.

____________________________________________________

_______________________________

Signature

Date

Automatic Payment Request Form - Paper City Savings Association