ACH Deposit/Withdrawal Authorization
You may complete this form online and print to sign and then fax or mail to
the location indicated.
__________________________________________________________________________________________________________________________
2805 Bowers Ave
Santa Clara, CA 95051
Fax: 408-731-4068
First Name
Middle Initial Social Security Number
Last Name
"From" Account Number:
“To” Account Number:
Is this a KeyPoint Credit Union Account?
Is this a KeyPoint Credit Union Account?
Account Type
Account Type
Yes No
(If "no," attach voided check)
(If "no," attach voided check)
NoYes
Checking Savings
SavingsChecking
This authorization is a:
New
Change
Cancel
Transfer Amount Frequency Date for Payment
Loans
Loans
"From" Account Number:
“To” Account Number:
Is this a KeyPoint Credit Union Account?
Is this a KeyPoint Credit Union Account?
Account Type
Account Type
Yes No
(If "no," attach voided check)
(If "no," attach voided check)
NoYes
Checking Savings
SavingsChecking
This authorization is a:
New
Change
Cancel
Transfer Amount Frequency Date for Payment
Loans
Loans
Day Time Phone Number
Date
Member's Signature
__________________________________________________________________________________________________________________________
Received Date:
Information Verified By:
Ownership Acct# Rtg# Date Entered:
CD Interest
For KeyPoint Credit Union use only:
I hereby authorize KeyPoint Credit Union to transfer funds, as listed above, between my accounts at KeyPoint Credit Union and another
financial institution, and if necessary, to make adjustments for any errors. KeyPoint Credit Union will be responsible for the transfer
of funds in accordance with this authorization. Once a transfer is made to another financial institution, KeyPoint Credit Union will have no
further responsibility or liability for deposit of such funds. Written notification must be received in sufficient time to afford KeyPoint Credit
Union a reasonable opportunity to act on notification. This authorization will remain in effect until KeyPoint Credit Union has received
written notification from an authorized signer on my account to change or cancel this authorization. My signature below acknowledges
that I have received a disclosure and agreement regarding the terms and conditions governing Credit Union electronic services. I
acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law.
External Financial Institution Information
(Only if "To" or "From" Account is not a KeyPoint Credit Union account. A Voided Check MUST be submitted along with this form,
for these requests.
Name of Financial Institution:
State
City
Address
Phone Number:
ABA/Transit Routing Number:
Zip
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CD Interest
