OLD Authorization Agreement for Automated Entries

Name*

First NameMiddle InitialLast Name

Business Name ( if Applicable)

Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code

Email*

example@example.com

Phone Number*

Area CodePhone Number

Financial Institution to Debit*

Routing Number*

What is your account number?*

What type of account are you making your payment from? *

Loan Account Number:*

Remove leading zeros.

Payment Amount*

Important Notice*

New agreements must be submitted 5 days prior to first payment date. If first payment date is within 5 days of submission, you will need to use a different payment method to satisfy the first payment. If you have questions, please contact your lender.

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 the month for your payment.

NOTICE: New agreements must be submitted 5 days prior to first payment date. If first payment date is within 5 days of submission, you will need to use a different payment method to satisfy the first payment.

Please choose the second date of the month for your payment.

Choose 1-31

By signing below I hereby authorize Better Banks 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, if my payment is returned unpaid, I authorize Better Banks to make a one-time electronic fund transfer from my account to collect a $25.00 returned item processing fee.

I understand that if the payment is being transferred from my Better Banks account and the transfer fails due to insufficient funds, the Bank will continue to attempt the payment transfer each day until successful.

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

Signature*

Enter the message as it's shown*