ACH Debit Authorization Form

The purpose of this form is to authorize the credit union to debit your account at another financial institution, in order to repay a loan or to fund, one time, a new membership with the credit union. Please note: This form must be submitted at least five (5) business days prior to the desired payment date.

Member Information

Member Name
Apply funds to my credit union account type (Choose one):
One time to my fund:
Recurring to pay my:
Date:

I authorize Lewis Clark Credit Union to debit my Financial Institution.

Check One:

I hereby authorize Lewis Clark Credit Union (LCCU) to initiate a charge (debit) entry at the Financial Institution indicated above, and initiate adjustments (if necessary) for any transactions debited in error. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. This authority will remain in effect until LCCU is notified by me in writing to cancel it in such time as to afford LCCU and Financial Institution a reasonable opportunity to act on it. 

I understand that if the funds are not available in my account on the designated debit date, I will be charged a Non-Sufficient Funds (NSF) fee. See Rate and Fee Schedule for fee and details. 

Lewis Clark Credit Union has the right to terminate, suspend, and audit compliance with agreement of ACH Rules and Regulations on ACH Origination Activity.

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Date

LCCU use

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