Ach Credit Authorization Form printable pdf download

Ach Credit Authorization Form

Teller #

ACH Credit Authorization

I (we) hereby authorize MidWest America Federal Credit Union, hereinafter called COMPANY, to initiate credit entries for deposit to my (our) account

indicated below and the financial institution named below, hereinafter call FINANCIAL INSTITUTION, to credit 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.

Name on Account to Credit ______________________________

Financial Institution receiving deposit _______________________

Start Date _______________ Amount $ ___________________

Account # to Credit ________________ Phone # _____________

Type of Account

: o Savings o Checking o Loan

Financial Institution Routing Transit Number

_______________ (9-digits)

____ ____ ____ ____ ____ ____ ____ ____ ____

Frequency

: o Weekly o Biweekly o Monthly

Please CANCEL my automatic:

loan payment or

deposit for the amount of $ ___________

as of [date] _______________ with [financial institution’s name] _________________________________________

This authorization is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination

in such time and manner as to afford COMPANY and FINANCIAL INSTITUTION a reasonable opportunity to act on it. If the item, in the above

authorization, would be returned to MidWest America Federal Credit Union, (for any reason other than stop payment) the normal NSF fee will apply.

Likewise, MidWest America reserves the right to cancel the above authorization, if the attempt to perform the above transaction, causes excessive

derogatory conditions. Please allow at least 30 days following prenotification before the item will be disbursed.

____________________________________ Signature ____________________________________________

Print Individual Name

_____________________________ Share ID ________________ Date ___________________

MidWest America Account Number

Please mail the original copy of this form along with a copy of your VOIDED check to:

ACH DEPARTMENT | MIDWEST AMERICA FCU | 1104 MEDICAL PARK DRIVE | FORT WAYNE, IN 46825

If you have any questions, please call 800-348-4738 ext. 4100.

o Approved o Denied Manager’s Signature ______________________________________ Date _________

FORM 10041 (03/13)

Ach Credit Authorization Form