Fillable Authorization Agreement For Automatic Payment

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Authorization Agreement For Automatic Payment

On average this form takes 8 minutes to complete

The Authorization Agreement For Automatic Payment form is 2 pages long and contains:

  • 3 signatures
  • 0 check-boxes
  • 18 other fields

Country of origin: US
File type: PDF

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Instructions to Complete the
Authorization Agreement for Automatic Payment
To redirect your automatic payments to your new account at American Savings Bank,
you must present a completed Authorization Agreement for Automatic Payment form
(“Form”) to the company (“Company”) that is currently making an automatic
withdrawal/payment from your current account. Please follow the instructions below to
complete the Form.
Instructions:
1. Enter the Company’s contact information.
2. Enter your personal information (name, address, phone number).
3. Enter the applicable account or policy number to which your automatic
withdrawal/payment is applied.
4. Enter the effective date of the change. (Confirm with the Company about the
timing of the change; it may not be an immediate change).
5. Enter information about your current account (bank, account number).
For checking accounts, your account number is typically located at the bottom of
your checks; see image below for an example.
Use the account number
shown here on your
checks (use the full 10-
digit number.)
VOID
6. Enter your American Savings Bank account information (indicate the appropriate
type of account and your account number).
Note:If making a payment from a checking account, print, complete and sign the
Form and attach a voided check from your American Savings Bank
checking account. Write “Void” across the check. Please do not use a
deposit slip.
Authorization Agreement
for Automatic Payment
To (“Company”): ___________________________________________
Address: ___________________________________________
City, State, Zip: ___________________________________________
Phone Number: ___________________________________________
From: ___________________________________________
Address: ___________________________________________
City, State, Zip: ___________________________________________
Phone Number: ___________________________________________
I authorize the Company to initiate automatic payment debit entries for
Account/Policy#: ___________________________________________
from my account with American Savings Bank listed below, and to debit those payments
from that American Savings Bank account. This authorization shall remain in full force
and effect until the Company has received written notification from me of its termination
in a manner and at a time that allows the Company a reasonable opportunity to act on it.
If you have any questions, please contact me.
Effective ___________________________, please cancel any automatic payments
from:
Current Financial Institution: _____________________________________
Current Account Number: _____________________________________
and redirect
the automatic payments from my American Savings Bank account as
follows (see attached check):
American Savings Bank
Bank Routing Number: 321370765
Address: P.O. Box 2300, Honolulu, HI 96804-2300
Phone: 627-6900 (Oahu), 1-800-272-2566 (Neighbor Islands)
Account Number: ____________________________________________
Account Type:
□ Checking □ Savings/Money Market Account
Signature: ________________________________ Date: ________________
Signature: ________________________________ Date: ________________
Signature: ________________________________ Date: ________________
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Authorization Agreement For Automatic Payment

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Completed 3 July 2020

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