Blank ACH Form - IUEC 38

ACH Authorization Form
Select One:

ADD (New Participant)Change (Financial Institution/Acct. Info)
Name (as it appears on the account)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Member Number (Intl. or NEIEP)
Email Address
example@example.com
Institution Name
Branch
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Routing Number
Account Number
Account Number Information

CheckingSavings
According to the information provided on this form I hereby authorize IUEC Local 38 to make withdrawals from my checking/savings account on a recurring monthly basis for the purpose of dues collection. I understand that should the monthly dues amount change in accordance with our governing documents, the automatic withdrawal amount will be automatically updated to reflect this change, unless otherwise instructed by me, in writing.

I understand that I may terminate this agreement at any time by providing written notice not less than 10 days prior to the next scheduled withdrawal. This authorization is to remain in effect until IUEC Local 38 receives a written termination or change notice from me.
Signature

Clear
Date

MonthDayYear
Date
Start Month/Year
1st Withdrawal Date (20th)

MonthDayYear
Date
TERMS & CONDITIONS
- Withdrawals will be made on the 20th of each month.
- The withdrawals will occur no earlier than the chosen scheduled withdrawal date. lf a scheduled withdrawal date falls on a weekend or holiday,
  the withdrawal will be initiated on the next regular business day.
- lf the dues amount changes in accordance with the local's governing documents, the automatic dues payment will be automatically updated to
  reflect this change, unless instructed otherwise by the applicant in writing.
- lf a withdrawal or transaction fails due to insufficient funds in the account, the withdrawal will automatically be reattempted approximately 10
  dayslater. lf the second attempt comes back due to insufficient funds, this transaction will be treated as an NSF(non-sufficientfunds) check and
  subject to a 530.00 NSF charge. A letter of NSF notice will be sent and all automatic withdrawals will stop until the NSF payment is received by
  cashier check or money order.
- lf two separate NSF transactions occur in a one year period, the applicant will not be eligible for the automatic dues withdrawal option for 2 years.
- ACH withdrawals are only available for recurring automatic withdrawals and are not subject to any fee.
- Signed automatic payment agreements may be terminated at any time by providing written notice no less than 10 days prior to the next schedule
  withdrawal.
Should be Empty:

ACH Authorization Form

TERMS & CONDITIONS