ACH LOAN PAYMENT AUTHORIZATION
409 Silverside Road, Suite 105
Wilmington, DE 19809
P: 866.221.5307
F: 302.791.5787
www.thebancorpbank.com
02/2013
Banking Services Provided by The Bancorp Bank
I/We authorize the Bank to electronically transfer funds through the Automated Clearing House (ACH) system from my/our deposit account
at the Financial Institution identified below to the Bank in payment of the below-referenced loan.
I/We understand that transfers will be made monthly, on the due date of the loan payment. If the due date falls on a holiday or non-business
day, the transfer will be made the next business day. I/We acknowledge that the origination of ACH transfers to my/our account must comply
with the provisions of U.S. law. This authorization will remain in effect until I/we have canceled it in writing. For one-time transfers, the ACH
will be processed on the date the Bank receives this completed and signed form unless it is received after business hours; in which case it
will be processed on the next business day.
You are not required to make your loan payments by electronic funds transfer.
PART 1: Loan Account with Us (“Transfer to”)
Loan Account Name: Loan Account Number:
PART 2: Other Financial Institution Information (“Transfer from”)
Account Name: Account Number:
Account Type:
Personal: q Checking or q Savings Commercial: q Checking or q Savings
Financial Institution Name: ABA Routing Number:
(Please verify number for ACH transfer
with the financial institution.)
Financial Institution Address:
(City and State)
PART 3: Payment Information
Amount of Monthly Loan Payment:
q One time ACH of $________________
q Exact Amount Billed
q Exact Amount Billed plus $_________________ additional principal each month
q Fixed monthly payment of $__________________. I understand that should the
monthly interest accrual exceed this amount I will have unpaid interest accrual
and this interest will remain unpaid and due on my account.
PART 4: Signature(s) of Owner(s) of Account at Other Financial Institution
Each owner of the account to be debited must sign the authorization below.
If more than two individuals own the account, please contact us for an additional signature page.
Signature of Authorized Signer #1:
Print Name: Date:
(mm/dd/yyyy)
Signature of Authorized Signer #2:
Print Name: Date:
(mm/dd/yyyy)
Please mail or fax this completed form to:
The Bancorp Bank, Attn: Loan Department
409 Silverside Road, Suite 105, Wilmington, DE 19809
Fax: 302.791.5787 (If possible, please send us an email alerting us to the incoming fax.)
Email: loanoperations@thebancorp.com
To protect your account information, please do not return this form by email, which may be unsecure.
PLEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS.
FOR BANK USE ONLY
Date Received:
(mm/dd/yyyy)
Date ACH Set-up Completed: Processed by:
