□
□
□
□
□
□
□
□
□
□
Member Number: _________________________
Name:___________________________________________
Address:__________________________________________
Visa Credit Card Auto Pay Authorization
n Indicate your request: Start Auto Pay Change Existing Set Up Cancel Auto Pay
o Select a payment option:
Minimum Payment Last Statement Balance Set Amount $
p Specify one payment account:
Checking Account
:
Inspirus Account Number
Checking sub #
Other Financial Institution Checking Account: a voided check must be attached
Savings Account:
Inspirus Account Number Savings sub #
Other Financial Institution Savings Account
Financial Institution Name:
Routing Number (9 digits):
Savings Account Number:
q Read, sign and date the authorization
I authorize Inspirus Credit Union, a Division of Gesa Credit Union to initiate debit entries on the payment due date,
and to initiate, if necessary, adjustments for any entries made in error to my account indicated above. This
authority will remain in full force and effect until Inspirus Credit Union has received a written notice of its termination
in such time and manner as to afford Inspirus Credit Union and the receiving financial institution a reasonable
opportunity to act on it. Inspirus Credit Union reserves the right to cancel this agreement at any time.
Signature: Date:
A request to Start Auto Pay from your Inspirus CU account requires your signature.
A request to Start, Change or Cancel Auto Pay from another financial institution requires your signature.
