ACH Origination authorization Agreement

Formation Credit Union Member Information

Name:*

Member Number*

Share Number

Loan Number

Financial Institution Information

Depository Institution Name:*

Routing Number*

Must be 9 digits

Account Number*

Check One*

Savings
Checking
Loan

ACH Origination*

Incoming: (credit a Formation Credit Union Share/Loan Account) As a convenience to me, I hereby request and authorize Formation Credit Union to initiate withdrawal entries from my account at the Depository Institution above in order to establish automatic transfer of funds and, if necessary, adjustments for any entries in error to my Formation Credit Union account. I also authorize the Depository Institution above to withdraw the same from such accounts.
Outgoing: (debit a Formation Credit Union Share Account) As a convenience to me, I hereby request and authorize Formation Credit Union to initiate debit entries from my Formation Credit Union account, payable to the Account/Depository Institution above, in order to establish automatic transfer of funds, provided there are sufficient collected funds in my account to pay such ACH debit.

Check One*

New
Cancel
Change

Change*

Financial Institutions
Amount
Date
Frequency

Amount $*

Effective/Start Date*

End Date*

Frequency*

One Time
Monthly
Semi-Monthly (14/28 or 15/last)
Bi-Weekly
Weekly

Member’s Signature/Authorization I understand that this authorization will remain in full force and effect until I notify Formation Credit Union, in writing, that I wish to revoke this authorization. I understand that Formation Credit Union requires at least 3 business days' notice prior to the next transfer date to guarantee a cancel of this authorization. I further agree that if any transfer of funds is returned UNPAID, whether with or without cause and whether intentionally or inadvertently, there will be a $30.00 Non-Sufficient Funds fee drafted from my Formation Credit Union account for each return. The authorized transfer will be canceled after the second return due to unpaid funds notice from Depository Institution, unless it is paying a loan at Formation Credit Union. In which case, the authorized transfer will try again on the next transfer date. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of United States law.

Member Signature*

If submitted by 11am Monday-Friday, it will process that business day; if submitted after 11am, it will be processed on the next business day. Please allow 2-3 days for completion.

Date