1440 Rosecrans Ave.
Manhattan Beach, CA 90266
800.854.9846 • www.kinecta.org
ACH DEBIT AUTHORIZATION
AGREEMENT – CREDIT CARDS
RETAILSERVICES
KFCUD17395-07/17
Kinecta Loan Account Number
I hereby authorize Kinecta Federal Credit Union (Kinecta), to initiate the electronic transfer indicated below at the depository financial institution named
below, and to debit the same to such account. I agree to indemnify Kinecta for any losses by complying with this authorization to debit my account. Also,
I acknowledge that these debit entries to my account will be conducted according to the National Automated Clearing House Association Rules (NACHA
Rules). I affirm that I have ownership and withdrawal rights on the accounts referenced below.
By agreeing to a “Debit Authorization”, you authorize Kinecta to initiate a debit entry (withdrawal, transfer, etc.) at the listed financial institution that
you provided. Items returned for non-sufficient and/or uncollected funds may be re-presented for payment. Fees for returned items will be charged in
accordance with the current Kinecta Schedule of Fees and Charges.
Account Type
Name on Acct
Bank Name
Account Number
Bank Routing #
Bank City/State
Checking Savings
Payment Options: (Check one)
One-Time Payment Option:
One-Time Payment Amount $ ______________ Payment Date: ______________
Recurring Payment Options:
Minimum Payment due (Shown on monthly statement)
Full Statemented Balance
Fixed Dollar Amount $ ______________ (indicate amount)
Starting Monthly on Due Date: ______________________
This authorization is to remain in full force and effect until Kinecta has received written notification from me of its termination. I agree to provide this
written notification at least 10 banking days in advance of the termination date so as to afford Kinecta and the named financial institution a reasonable
opportunity to act on it. This authorization may be unilaterally terminated by Kinecta in cases of excessive returns or member abuse, or whenever any
loans have been paid in full with recurring debits.
If you have further questions, please contact our 24-hour Card Service Department at 877.881.6023. Please mail your completed ACH form to the
address listed above or fax to 310-727-8208.
_______________________________ _______________________________
Member Signature Member Name (print)
________________________________ _______________________________
Date Daytime Phone Number
MEMBER AUTHORIZATION:
For Credit Union Use Only
Please send completed forms to Document & Workflow CU/36
Branch Number _____ Branch Manager ______________________________ Branch Phone Number ______________________________
*** YOU MUST BE THE OWNER ON BOTH FROM AND TO ACCOUNTS ***
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