Please return form to:
Accounting Office, Old Morrison Room 100, Transylvania University, 300 N. Broadway, Lexington, KY 40508
(859) 233-8150, Fax (859) 281-3506 E-mail:
Bagby and/or Schell Automatic Monthly Payment Form
This form is used for authorizing Transylvania University to withdraw Bagby and/or Schell Loan payments
directly from your bank account each month.
Name: Account Holder ID:
Street Address:
City: State: Zip:
Phone: ___________________ Email:
Type of Loan: Bagby Schell
Start Date: (mm/yy) / (withdrawals will be made on the last business day each month)
Type of account: Checking Savings Monthly Amount: $
Bank Name:
Routing No. (9 Digits): Account No. :
If withdrawal is from your checking account, please attach copy of VOIDED check - see example below
I hereby authorize and request Transylvania University to make monthly withdrawals in the amount listed
above by initiating debit entries to my account indicated on the voided check copy provided, and I authorize
and request my bank to accept debit entries initiated by Transylvania University to such account. It is
understood that this agreement may be terminated by me at any time by written notification to
Transylvania University. Any such notification to Transylvania University shall be effective only with respect
to entries initiated by Transylvania University after receipt of such notification and a reasonable opportunity
to act on it.
Signature: Date:
click to sign
click to edit