Automatic Loan Payment Authorization

Automatic Loan Payment Authorization

Please allow up to 7 business days for this form to be processed. If not completed in full it may result in a late loan payment.
I hereby authorize North Iowa Community Credit Union (NICCU) to initiate a debit entry to my account indicated below and the financial institution named below, hereinafter called FINANCIAL INSTITUTION, to debit the same to such account. I acknowledge that the origination of ACH transactions or transfers to my account must comply with the provisions of U.S. law.
Full Name*

First NameLast Name
Phone Number*

Area CodePhone Number
What type of payment are you setting up?

New loan paymentUpdating an existing loan paymentCanceling an existing loan payment
Where is your payment coming from?

Within NICCUOther Financial
NICCU Internal Transfer

From an existing NICCU Account
Member Number
Type of Account Transferring from:

CheckingSavings
Checking Account Type

Free Checking (077)Fresh Start Checking (078)Business Checking (076)Premium Checking (075)Other
Savings Account Type

Primary Membership (001)Blue Chip Savings (040)Passbook Savings (030)Other
Payment Amount:*
Loan Number
Transaction Beginning on:

MonthDayYear
Date
Cancellation Beginning on:

MonthDayYear
Date
And will continue thereafter:

MonthlyWeeklyBi-weekly
Transfer from Other Financial
Financial Institution Name
Financial Institution Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Routing Number of Other Financial
Account Number of Other Financial
Type of Account Transferring from:

CheckingSavings
Payment Amount:*
NICCU Member Number*
NICCU Loan Number*
Transaction Beginning on:

MonthDayYear
Date
And will continue thereafter:

MonthlyWeeklyBi-weekly
Additional Comments:
Review, Sign and Date for New/Updated Transfers

This agreement is to remain in full effect until North Iowa Community Credit Union has received written notification from all initial signers of its termination in such time and manner as to afford NICCU and other FINANCIAL INSTITUTION a reasonable opportunity to act on it. A new form can be used to cancel Payment Transfer Authorization at time of termination.

When you apply electronic signature with North Iowa Community Credit Union you are bound with the same force and effect as if you had signed on paper. By signing below, I authorize automatic payment transfer and understand it is my responsibility to maintain a balance in my NICCU account to enable the transfer to be made on the specified date. The transfers will continue until I notify NICCU in writing to cancel or update the transfer or if NICCU notifies me the transfer will be discontinued. NICCU must receive the written request for cancellation seven (7) business days prior to the transfer. Payments will stop automatically when loan is paid in full. If remaining balance of loan is less than the payment amount, the loan will be paid and any additional funds will be placed in your membership savings account. NICCU reserves the right to charge a fee if payment is returned for any reason.
Electronic Signature:

Clear
Today's Date

MonthDayYear
Date
Review, Sign and Date for Cancellation Only

I understand that by signing the cancelation line below that my payments will no longer be taken out of my account automatically for the completed loan information above. If the loan was not paid off, then it is my responsibility to make other payment arrangements to avoid delay in payment.
Electronic Signature:

Clear
Today's Date

MonthDayYear
Date
Should be Empty:

Automatic Loan Payment Authorization

NICCU Internal Transfer

Transfer from Other Financial