Authorization For Automatic Payment  

I (we) authorize ISU Community Credit Union to initiate a debit from my (our) checking account at the financial institution named below. I (we) also authorize the above named credit union initiate if necessary a debit or edit entry to correct or adjust any entry made to my (our) account in error. This authority will remain in effect until I notify in person or in writing, either financial institution to cancel the authorization in such time as to afford the financial institution a reasonable opportunity to act on it. 

Staple Voided Check Here                              Financial Institution Information  

 Payment Information

Payment is to be made on the following day(s) of the month In the amount of $_________________________________ with the starting date of_____________

Member Signature _____________________ Date ___________  

Credit Union Employee_____________________Date___________

Mail Form to CCF - Box 1038 - Ames, IA 50014