ACH Form

First Name

Last Name

FF Member Number

Checking, Savings, or Loan #

Amount of ACH

Transaction coming into EFFCU or going out of EFFCU account?

Name of Financial Institution

Routing Number

Start Date

End Date

Frequency

Account: Checking, Savings, or Loan #

Account Holder Name and Number

Signature:
You may identify the payee or any financial institution by name and by account number (or ABA routing number). The Credit Union (and other institutions) may rely on the member or other identifying number as the proper identification, even if it identifies a different party or institution. If the ACH transfer is cleared through the Federal Reserve, the transaction is governed by Regulation J. You authorize the Credit Union to transfer funds as described herein and debit your account in the amount transferred.

Full Name

Date

I agree and understand that by checking the box below, I acknowledge and consent that the above typed name is my electronic signature. This electronically typed signature is the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.

Yes, I agree and accept this information concerning my digital signature.

312 N 4th Ave

(812) 424-9396

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ACH Form

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