JACKSONVILLE STATE UNIVERSITY
BURSAR’S OFFICE
AUTOMATIC MONTHLY LOAN PAYMENTS
(for Perkins, and/or Logan Walker Loans)
Jacksonville State University now offers a convenient method for you to make your Perkins and/or
Logan Walker loan payment(s). By completing the authorization form below and returning it, your
monthly loan payment will be made by an automatic charge to your Visa, MasterCard, Discover or
Debit Card containing the Visa or MasterCard logo. The transaction will occur on the date you
specify, otherwise, the transaction will occur on the due date, which is the 15
th
each month.
If you are interested in this convenient way to make your payments, complete the Authorization
Agreement below and return it to:
Jacksonville State University
Bursar’s Office
700 Pelham Road North
Jacksonville, Alabama 36265-1602
Fax: 256-782-8067
Please continue to make your monthly payment until the date you have chosen to begin the
Automatic Monthly Payment.
--------------------------------------------------------------------------------------------------------------------------
Authorization for Automatic Credit Card/Debit Card Charge
I authorize Jacksonville State University to automatically charge my Credit Card/Debit Card
account as specified below for the amount of my monthly Perkins and/or Logan Walker loan
payment(s). I agree that each payment will be the same as if it were a check personally signed by
me. This authority will remain in effect until revoked by me in writing to the Bursar’s Office or
until my loan(s) are paid in full. I understand that this method of payment may be canceled if my
credit card company denies two (2) transfers in any twelve (12) month period.
( )
Name Student # Daytime Phone #
Address City State Zip Email Address
Credit Card Account Number Expiration Date Verification code (last 3 digits on signature line, back of card)
Is this a credit ________ or debit _________ card?
Loan Type: Perkins ______________ Logan Walker Loan _________________ Amount to be deducted each month $ __________________________
Circle the date for payment: 3
rd
- 10
th
- 15
th
of each month, beginning with the month of _____________________, 20____.
_____________
Signature of individual whose account will be charged (Debited)
