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ACH Authorization Form

(17 digits)

MM/DD/YYYY


I (we) herby authorize The Credit Union Loan Source, LLC, hereinafter called COMPANY, to initiate debit entries from my:
FREQUENCY:

Monthly One Time

$

Indicated above at the depository financial institution named below, hereinafter called DEPOSITORY, and to debit the same to such account. I (we) acknowledge that the origination of ACH transactions from my (our) account must comply with the U.S. law.

Saving/Checking Account: Routing numbers should be obtained from your financial institution. Routing numbers may consist of 9 digits. When entering in the above field, exclude spaces and special characters.


This authorization is to remain in full force and effect until COMPANY has received an ACH cancellation form of its termination by 12:00 EST as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it. A cancellation form is also required in order to cancel reoccuring drafts 72 hours prior to the draft date, due date or payoff date.

I hereby Authorize COMPANY to accept the checking of this box in lieu of my signature.(Online Submission)

NOTE: Debit authorizations must provide that the receiver may revoke the authorization only by notifying the originator in the manner specified in the authorization.
NOTE: Click submit once to avoid multiple submissions

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