ACH Payment Request

Authorization for ACH Payment

Direct Payment via ACH is the transfer of funds from a consumer account for the purpose of making a payment.
Member Number
First Name*
Middle Initial
Last Name*
Date of Birth*

MonthDayYear
Social Security*
Telephone Number (Mobile)*

Area CodePhone Number
Telephone Number (Home)

Area CodePhone Number
Email*
example@example.com
I(we) authorize Germania Credit Union to electronically debit my(our) account (and if necessary, electronically credit my(our) account to correct erroneous debits) as follows.
Account to Debit*

CheckingSavings
Depository Name*
Routing Number*
Account Number*
Amount of Debit*
Upload Image of Check

Browse Files

Cancelof
Frequency*
Start Date*

MonthDayYear
Date
Credit to GCU Account Number
Credit to GCU Loan Number
Terms and Conditions

I (we) understand that this authorization will remain in full force and effect until I (we) notify Germania Credit Union in writing, by telephone or coming into the credit union that I (we) wish to revoke this authorization. I (we) understand that Germania Credit Union requires at least 5 days prior notice in order to cancel this authorization.

Germania Credit Union
PO Box 645
Brenham,TX 77834-0645
(979)-830-7516 or 1-877-635-9405

clozano@germaniainsurance.com
Do you agree to the Terms and Conditions*

YesNo
Today's Date*

MonthDayYear
Date
Signature*
Should be Empty:

Authorization for ACH Payment