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 toI (We) acknowledge that the origination of ACH transactions from my account must comply with the previous of U.S. law. Omaha Federal CU Payment InformationStarting Date MM slash DD slash YYYY Payment Frequency (Pick One) Weekly Bi-Weekly Monthly Semi-Monthly Quarterly Other Payment Amount: Fixed Amount$Debit Credit Union Account Number: Savings Suffix # Checking Suffix #: Loan #: Destination InformationNAME ON ACCOUNT: First Last FINANCIAL INSITUTION: Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 PhoneSignatureDate MM slash DD slash YYYY 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.CAPTCHANameThis field is for validation purposes and should be left unchanged.