Loan Payments – Authorization Form

What type of payment would you like to make?
Transfer Type*
- One Time Transfer
- Recurring Payment
- Cancel an Existing Recurring Payment

How would you like to pay?
I (we) hereby authorize Chief Financial to initiate a debit entry to my/our:
Type of Debit*
- Savings
- Checking
- Visa/Mastercard
Financial Institution Transferring From:
Institution Name*
Account Holder Name*
Routing Number*
Account Number*
Visa / MasterCard Paying From:
Transaction processed as cash advance – cash advance fees may occur

NOTICE: Effective 10/1/2023, due to increasing merchant processing fees, there will be a $10 fee added to all loan payments made with a Visa or Mastercard. Payments made from savings or checking using your routing and account number will still be processed with no fee.
Is the cardholder the owner of the loan?*
- Yes
- No
Cardholder ID#*

State Issued ID or Driver's License
State Issued*
ID Expiration Date (MM/DD/YYYY)*
Cardholder's Name*
As it appears on the credit card
First Last
Expiration Date (MMYYYY)*
Credit Card Number*
Credit Card Fee
One Time Transfer
Amount (One Time)*
Total
Recurring Monthly Transfer
Amount (Recurring)*
Effective Date*
MM slash DD slash YYYY

* Effective Date is the date payment will credit your Chief Financial loan. Transfer will occur monthly on the business date prior to effective date until a Cancellation Request is submitted or the Credit Union is notified in writing.
Total
Cancellation of Monthly Transfer
Amount of Recurring Transfer*
Please cancel the above payment effective immediately. *Note: 3-5 business days prior to transfer are needed before cancellation can be processed

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