Fillable Authorization of Automatic Payment Withdrawal for Consumer Leases

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Authorization of Automatic Payment Withdrawal for Consumer Leases

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MMWR-46081 3/31/14 Version 1
Banker Name___________________ Phone________________
Authorization of Automatic Payment Withdrawal for Consumer Leases
Name: __________________________________________________________
Address: ________________________________________________________
City, State, Zip: ___________________________________________________
Lease Account Number: ____________________________________________
Deposit Account Number Account Type Financial Institution Name Routing/Transit Number
______________________ Checking* Savings ________________________ ______________________
*If checking, please attach a voided check.
NOTE: An automatic payment will occur each month regardless of any additional payments that are made to the lease
agreement.
Due Date and Payment Amount
- Your automatic payment amount and due date will be per your lease agreement.
See Terms & Conditions on the back of the form.
I authorize U.S. Bank to set up my Lease Account with Automatic Payments and to debit my Deposit Account and
credit my Lease Account as directed above. By signing this form, I understand and accept the terms and conditions
associated with this form. (See Terms and Conditions on back of form)
Signature_____________________________________________ Date _____________________
Signature ____________________________________________ Date _____________________
Customer Information – Please Print
Take Payment from the Following Deposit Account – See Terms & Conditions on back of form
Authorized Account Signers
Instructions:
1. Read Automatic Payment Terms & Conditions.
2. Please complete payment and transfer information in all sections below.
3. Sign and date in “Authorized Account Signers” Section
4. Return the completed form to:
U.S. Bank
Consumer Lease Maintenance – MK-WI-FCPT
P.O. Box 2188
Oshkosh, WI 54903-2188
Or fax to: 920.237.8867
5. Please keep one copy of this document for your records.
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MMWR-46081 3/31/14 Version 1
Consumer Lease Authorization of Automatic Payment Withdrawal
Automatic Payment Terms & Conditions
• Complete this form and attach a voided check from the deposit account that is to be debited each month.
• The form must be received and processed at least 5 business days before the next due date for the payments to
occur automatically. Contact U.S. Bank 24hr Banking at one of the numbers listed below to inquire on whether the
Automatic Payments have been established on your account.
• If Automatic Payments cannot be established as requested, a letter will be mailed to you with a brief explanation of
any issues. This may cause a delay in set up of your Automatic Payments. You will still be responsible to make any
billed payments until Automatic Payments have been established.
• You will not receive monthly billing statement while your account is set up on Automatic Payments unless
there are fees, taxes, or additional charges on the account. These additional assessments will not be
automatically deducted; they will instead be billed to you at the end of your lease term.
• If you choose to make additional payments outside of your Automatic Payment, your Automatic Payment will still be
debited from your Deposit account on each due date.
• Your Automatic Payment Due Date will be the contracted due date as indicated on your lease agreement.
• Your Automatic Payment Amount will be the contractual amount due as indicated on your lease agreement.
• If your due date falls on a weekend or a holiday, the Automatic Payment will be debited from your Deposit account
on the following business day.
To cancel Automatic Payments, U.S. Bank must be notified at least three business days prior to the applicable
payment date by calling U.S. Bank 24hr Banking at one of the numbers listed below. If the Automatic Payment is not
cancelled in time, the system will still debit the payment from your Deposit account.
Any fees assessed to your account such as late or insufficient funds will be due at the end of your lease term.
To change your contractual due date, a fee may apply. Please contact U.S. Bank 24hr Banking at one of the
numbers listed below for assistance.
Conditions that may cause the Automatic Payment to be cancelled on your account:
-If your Automatic Payment has been returned due to insufficient funds for three consecutive payments. A payment
returned as insufficient funds may be assessed a fee which will be due at the end of your lease term.
-If we receive notice that your Deposit account has been closed or frozen, or is an invalid number. A payment returned due
to the Deposit account being closed, frozen or invalid may be assessed a fee which will be due at the end of your lease
term
Any questions regarding your account or Automatic Payments, please call one of the service centers below:
U.S. Bank 24-Hour Banking
Denver area 303.585.8585 Milwaukee area 414.765.4636
Cincinnati area 513.632.4141 Portland area 503.USBANKS (872.2657)
St. Louis area 314.425.2000 Minneapolis/ St. Paul area 612.USBANKS (872.2657)
TDD access 800.685.5065 All other areas 800.USBANKS (872.2657)
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Authorization of Automatic Payment Withdrawal for Consumer Leases

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Completed 9 December 2021

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