Automatic Payment Request Form Page 5
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6Automatic Payment Request Form
Payee Name: _______________________________________________________________
Payee Address: _____________________________________________________________
City: ____________________ State: _______ Zip: _________________________________
Payee Phone: __________________ Payee Fax: __________________
Account Holder Name: _________________________ Account Number: __________________
Address: ____________________________________________________________________
City: _____________________ State: ________ Zip: ______________
Home Phone: __________________ Work Phone: __________________
To Whom It May Concern:
You are currently withdrawing $ _____________ (amount) for my _______________________
(mortgage, utilities, insurance, etc.) from:
Financial Institution Name: __________________________________________________
Routing Number of Institution: _______________________________________________
Account Number: _________________________________________________________
As of ____________ (date), please start taking this automatic payment from my account at:
Capital Educators Federal Credit Union
Account Number: __ __ __ __ __ __ __ Account Type:
Checking
Savings
Routing Number: 324172575
If you have any questions about this request, please contact me at ______________________.
Printed Name: _______________________________________________________________
Signature: _________________________ Date: ____________________________________
**Complete and send this form to each company where you have an arrangement for automatic
withdrawal. Print one form for each company.
CapEd · P.O. Box 570 · 275 S Stratford Dr · Meridian, ID 83680 · (208) 884-0150 ·
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