Name of Payee/Merchant
Account Number with Payee/Merchant
Address
City State Zip
Name of Financial Institution
Routing Number
Account Number
Account Number
______________(date)
Signature
Print Name Phone
Address
City State Zip
This document contains both information and form fields. To read information, use the Down Arrow from a form
field.
Automatic Payment Change Form
An Automatic Payment is when you authorize a Payee/Merchant to electronically withdraw funds from your checking account
to pay a recurring bill (power, phone, cable, etc). These authorizations can be changed by preparing this form and sending it
to the Payee/Merchant or by visiting their website and making the changes online with your new account information with
SECU.
Payee/Merchant Information
Exist
ing Account Information
New Account Information
Name of Financial Institution State Employees’ Credit Union
Routing Number 253177049
Your SECU checking account number will begin with 086 plus your 8-digit checking account number.
If the account number is not equal to 8 digits you will need to include leading zeros before the
account number but after the 086.
The full account number with 086 should equal 11 digits.
Authorization
Effective , please stop debiting my existing account for this payment
and begin debiting my new account. Please provide written confirmation when this change
has been completed.
APC – V1
