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Direct Payment Authorization



To authorize direct payment of a CCU loan from an account at another financial institution print the following authorization agreement. Complete and sign the form and mail it along with a voided check to:

Campus Credit Union
1845 Fairmount Box 65
Wichita, KS 67260-0065

AUTHORIZATION AGREEMENT FOR DIRECT PAYMENT

I (we) hereby authorize Campus Credit Union, hereinafter called CREDIT UNION, to initiate debit entries to my (our) CHECKING SAVINGS account indicated below and the depository named below, hereinafter called DEPOSITORY, to debit same to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provision of U.S. law.

DEPOSITORY NAME _______________________________________

CITY ____________ STATE ____ ZIP _______

TRANSIT/ABA NO. _______________________

ACCT # _______________________________

The above account will be debited in the amount of
$_______ starting ______ day of _________ , 20__ and posted to my credit union account # ____________________

This authority is to remain in full force and effect until CREDIT UNION and DEPOSITORY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford CREDIT UNION and DEPOSITORY a reasonable opportunity to act on it.

NAME(S) _________________________________

DATE ____________________________________

SIGNED __________________________________

Please attach a deposit slip below, if applicable.