LCCU_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

First Name

Last Name

CU Member Number

Daytime Phone

Cell Phone

Member Email Address

Apply funds to my credit union account type (Choose one):

Checking Account Savings Account Loan

One time to my fund:

New Membership - Indicate the EXACT amount you want transferred to your account below

Amount from above

Recurring to pay my:

New Loan (complete info below)

Loan Number:

Payment Amount $:

Payment Frequency:

Date:

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

Check One:

New Request Change (describe below) Cancel

Description from above (if needed):

Name of Financial Institution:*

Location (City, State)*

Financial Institution 9 Digit Routing Transit Number:*

Account Number to Debit:*

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.

Member Signature:

[clear]

Use your mouse or finger to draw your signature above

Date

ACH Debit Authorization Form

LCCU use