Direct Payment Form

We are pleased to be able to offer you a new service, the Direct Payment Plan. Now you can have your payment made automatically from your checking or savings account and you won't have to change your present banking relationship to take advantage of this service.

Here's how the Direct Payment Plan works:

The Direct Payment Plan will help you in several ways. It saves time-fewer checks to write Helps meet your commitment in a convenient and timely manner-even if you're on vacation or out of town No lost or misplaced statements, your payment is always on time-it helps maintain good credit It saves postage It's easy to sign up for, easy to cancel No late charges

You authorize regularly scheduled payments to be made from your checking or savings account. Then, just sit back and relax. Your payments will be made automatically on the specified day. And proof of payment will appear with your statement. The authority you give to charge your account will remain in effect until you notify us in writing to terminate the auth_orization. If the amount of your pay ment changes, we will notify you at least 1 O days before payment date. The Direct Payment Plan is dependable, flexible, convenient and easy. To take advantage of this service, complete the attached authorization form and return it to us.

AUTHORIZATION FOR DIRECT PAYMENT
I Authorize (Type Company Name Below)*
to initiate entries to my checking/savings account. This authority will remain in effect until I notify you in writing to cancel it in such time as to afford the company a reasonable opportunity to act on it. I can stop payment of any entry by notifying my financial institution 3 days before my account is charged.
Name of your financial institution*
Branch*
City*
What city is your branch located?
State*
What state is your branch located?
Zip Code*
What is the zip code of where your branch is located?
Signature*

Clear
Date Signed*

MonthDayYear
Date of when you signed
Please type your name below*
Your address*
Account No.*
Account Type*

CheckingSavings
Financial Institution Routing Number*
Between these symbols |: |: on the bottom of the check
On this date*

MonthDayYear
Indicate date authorized
I Authorize (Type Company Name Below)*
The company you authorize
Address of Company*
Phone of Company*
to initiate electronic entries to my checking/savings account and have agreed to the terms listed on the authorization. I may revoke my authorization with you at any time by writing to the address above.
Initial Payment Amount ($)*
Regular Payment Date
ACH is pulled on the 5th of month unless it falls on a weekend or holiday, at which time it would be pulled on the next business day.ACH is pulled on the 5th of month unless it falls on a weekend or holiday, at which time it would be pulled on the next business day.
(if payment amount changes we will notify you at least 10 days before the regularly scheduled payment date.)
Should be Empty: