Automatic Payment Deposit Authorization - Omaha Federal Credit Union

Omaha Federal Credit Union's
Automatic Payment/Deposit Authorization

(For Payment From Omaha FCU)

I hereby authorize Omaha Federal Credit Union, hereinafter called CREDIT UNION, to initiate a debit entry from my (our) account indicated below at Omaha Federal Credit Union to

I (We) acknowledge that the origination of ACH transactions from my account must comply with the previous of U.S. law.

Omaha Federal CU Payment Information

Starting Date

Payment Frequency (Pick One)

Payment Amount: Fixed Amount$

Debit Credit Union Account Number:

Savings Suffix #

Checking Suffix #:

Loan #:

Destination Information

NAME ON ACCOUNT:

First Last

FINANCIAL INSITUTION:

Address

Street Address Address Line 2 City State ZIP Code

Routing Number:

Account Number

Account Type:

Checking

Savings

Loan

This authorization is to remain in full force and effect until the CREDIT UNION and DESTINATION a reasonable opportunity to act on. Omaha Federal can terminate this contract at any time for insufficient funds activity.

Name

First Last

Phone

Signature

Date

Please note: There will be a $15.00 fee for an add/change/delete.

*** PLEASE ATTACH COPY OF VOIDED CHECK TO THIS FORM ***

Max. file size: 32 MB.

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