ACH Payment Authorization Form

Name *

First

Last

Borrower Name *

Phone number for Borrower *

Address of primary property securing the loan *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing address for Borrower *

Address Line 1

Address Line 2

City

State

Zip Code

Name of Bank *

Account Type *

Account Number *

Routing Number *

Day of month for automatic withdrawal *

Withdrawals will be made on this day each month, or the next business day.

Payment amount *

Authorization *

I/We hereby authorize a monthly ACH electronic debit from the account designated above to be paid to FCI Lender Services, Inc., in payment of my/our monthly loan obligation, not to exceed the amount agreed to by me/us below. Provided however, if the required scheduled loan payment changes for any account related reason, including but not limited to change in principal balance, interest rate, or in required escrow/impounds, I/We authorize the debit amount to be adjusted accordingly. I/We understand that should my/our bank dishonor my/our automated payment for insufficient or uncollected funds, the original amount, plus an additional NSF fee, as allowed by law, may be electronically debited from my/our account. I/We authorize FCI to debit my/our account consistent with this Authorization until such time as I/we provide 15 days written notice to FCI of withdrawal of this Authorization. NOTE: The electronic debit date can not be changed with less than 15 days written notice prior to the next scheduled debit date sent to FCI Lender Services, Inc. at the address or fax numbers above

Signature *

Clear Signature