State of Illinois
Western Illinois University
Authorization for Automatic Withdrawal of Recurring Payments
(Perkins)
A. Borrower Name B. Borrower WIU ID# or SSN
C. Street Address of Borrower
City
State Zip
Phone
D. Borrower Email Address
E. Check One:
__ Checking Account __ Savings Account
F. Name of Financial Institution G. Name on Bank Account
H. Street Address of Financial Institution
City State Zip
I. Amount to be withdrawn each month: _________________
J. Month of First Withdrawal: ________________________
K. Transit/Routing Number
L. Bank Account Number
I authorize and request W
estern Illinois University to initiate automatic withdraw (ACH Debits) from my account on the first of the
month to be applied to my Perkins account. This authorization is to remain in full force and effect until the account is paid in full or the
authorizing person named below has given 30 days written notification of termination to the Billing and Receivables Office at WIU. If
the payment is more than the payoff amount, WIU will take the lesser amount. Completed forms received in our office by the 20th of
the month will result in deduction on the first of the following month. If funds are not available, you will be assessed a $25.00 ACH
returned service charge.
M. Signature
N. Date
****Please attach a voided check****
To be completed by depository financial institution
_________________________________________ __________________________________________
Financial Institution Name, City Bank Transit Routing Number
_________________________________________ __________________________________________
Account Holder Name Account Number
_________________________________________ __________________________________________
Bank Official Signature Phone Number
