State Street Bank- Authorization Agreement for Automated Entries

Name *

First Name Middle Initial Last Name

Business Name (If Applicable)

Address *

Street Address

Street Address Line 2

City State

Postal / Zip Code

Email *

example@example.com

Phone Number *

Area Code Phone Number

Financial Institution to Debit *

Routing Number *

Account Number *

Re-Enter Account Number *

Account Type *

Loan Account Number: *

Remove leading zeros.

Payment Amount *

Payment Frequency *

Please choose the day of the week for your payment

Begin Payment Date On *

Please allow at least 5 business days for processing.

Please choose the date of month for your payment

NOTICE: Your payment will begin on this date for the current month if the date has not already passed. If the date selected has passed for the current month then your payment will begin on this date next month. You will need to make other payment arrangements if this date has already passed for this month.

Please choose the second date of month for your payment

By signing below I hereby authorize State Street Bank to initiate debit entries to my deposit account indicated above and the depository named above to credit to my loan account. I acknowledge the origination of ACH transactions to my account must comply with the provisions of U.S. law.

I further acknowledge and authorize State Street Bank to make a one time electronic fund transfer from my account to collect a $25.00 return item processing fee if at any time a payment is returned unpaid.

I understand that this authorization will remain in full force and effect until I notify State Street Bank by phone or at any branch location that I wish to revoke this authorization. I understand that State Street Bank requires at least 5 business days prior notice in order to cancel this authorization.

Today's Date *

Signature *

Use your finger or mouse to sign. Clear

Enter the message as it's shown *