ACH Loan Payment Authorization

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ACH Loan Payment Authorization
47-ACH Loan Payment Authorization
ACH Loan Payment Authorization
New
Change
Cancel
ABA Number
Name of the Financial Institution to be Debited
City
Contact #
Account Number
Coastal Account Owner Name
State
Zip Code
Account Type To Be Debited
Checking
Name on Account
Savings
Account Number
I (We) hereby authorize Coastal Federal Credit Union (‘‘Coastal FCU’’) to DEBIT my account with the Debited Financial Institution named
above to make my scheduled payment with Coastal FCU. I (We) acknowlede that the origination of ACH transactions to my (our) account
must comply with the provisions of U.S. Law. I (We) understand that Coastal FCU is not responsible for any fees, penalties or late
charges, which may arise when funds are not available and the ACH debit is rejected. I (We) also understand that any rejected
debits may be resubmitted. Payment dates that fall on a non-business day will be posted on the next business day.
The automatic payment will be applied to the loan listed below, on a monthly basis. I request a debit amount of ___________________.
Note: If your final deduction is greater than your final payment, the remainder will be deposited into your Coastal FCU savings
account.
Loan ID #:
Mortgage Number
I (We) understand that Automatic Payments will begin on the first due date AFTER the submission of this form. Payments should be
remitted by check until that time. Please start my automatic payment on ___________________ (mm/dd/yyyy).
This authorization is to remain in full force and effect until Coastal FCU has received written authorization from an account owner of
its termination no later than 3 business days prior to the initiation of the next payment.
I also understand that if a change or cancel is requested this form supercedes any previous form(s) on file.
Note: Two consecutive failed payments may result in termination of the automatic debit from the other institution.
Account Owner Name
Signature
Please return completed form to:
Coastal Federal Credit Union
Attn: Payment Services
PO Box 58429, Raleigh, NC 27658
Phone: 1-800-868-4262
Fax: 1-866-881-5533
Date
1
47-12/2015

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