ACH Recurring Payment Authorization Form

ACH Recurring Payment Authorization Form

  • Section I - Member Information

  • Section II - Financial Institution Information

  • Date Format: MM slash DD slash YYYY
  • Section III - Allocation of Funds at LCU

  • Comments

  • Payment Authorization

  • I hereby authorize Lowland Credit Union to initiate debit entries and to initiate, if necessary, credit entries and adjustments for any debit entries in error to my account indicated in Section II. I understand that this authorization will remain in effect until Lowland Credit Union has received written notification from me. I agree to notify Lowland Credit Union in writing of any changes in my account information or termination in such time and in such manner as to afford Lowland Credit Union a reasonable opportunity to act on it. I understand that Lowland Credit Union will not attempt to process the debit entry again should the payment be returned as NSF. If the above noted periodic payment date falls on a weekend or holiday, I understand that the payment may be executed on the next business day. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of the U.S. law.
  • Date Format: MM slash DD slash YYYY
  • Revocation

    Please sign below if you wish to cancel this transfer.
  • Date Format: MM slash DD slash YYYY