Banker Name Phone
Authorization of Automatic Payment Withdrawal for Consumer/Business Loans and Lines of Credit
Name: _
Address: _
City/ State/Zip: _
Loan/Line Account Number:
Deposit Account Number Account Type Financial Institution Name Routing/Transit Number
Checking* Savings
*If Checking, please attach a voided check.
Payment Amount*
Minimum Payment Due -As per your original agreement or contract
Other Monthly Payment amount $ (This option is not available for accounts with Escrow)
Note: ‘Other Monthly Automatic Payment amount’ must be equal to or greater than the total monthly payment due per your original contractual
Agreement. If you indicate a payment amount that is less than your original contractual Agreement, the Automatic Payment form will be returned to you.
If you are escrowing taxes and/or insurance, you will receive an Escrow Analysis Statement in the mail reflecting the updated escrow portion of the
payment.
*Note: Any fees that are assessed to your account may be added to your monthly automatic payment amount. See Terms &
Conditions on back of form for details
Due Date -As per your note, agreement or contract. See Terms & Conditions on back of form for details.
Bi-weekly Payment Option
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(1/2 of your monthly contracted payment)- Beginning on / / for $ each
I authorize U.S. Bank to set up my account with Automatic Payments and to debit my Deposit Account and credit my account as
directed above. By signing this form, I understand and accept the terms and conditions associated with this form. (See Terms and
Conditions on back of form)
Signature Date
Signature Date
Take Payment from the Following Deposit Account- See Terms & Conditions
on back of form
Customer Information-Please Print
Payment Option Type and Amount - See Terms & Conditions on back of form
Multiple Payment Option- Fixed Rate Loans Only - See Terms & Conditions on back of form
Authorized Account Signers
Instructions:
1. Read Automatic Payment Terms & Conditions.
2. Please complete payment and transfer information in all sections
below.
3. Sign and date in “Authorized Account Signers” Section.
4. Return the completed form to:
U.S. Bank
Consumer Loan Maintenance – MK-WI-FCMT
P.O. Box 2923
Oshkosh, WI 54903-2923
Or fax to: 866-941-9753
5. Please keep one copy of this document for your records.
Automatic Payment Withdrawal Terms & Conditions – Loans and Lines of Credit
• Complete this form and attach a voided check from the deposit account that is to be debited each month.
• Automatic Payments will begin with the next unbilled statement cycle after the completed form has been received.
• If Automatic Payments cannot be established as requested, a letter will be mailed to you with a brief explanation of any
issues. This may cause a delay in set up of your Automatic Payments. Yo u will still be responsible to make any billed
payments until automatic payments have been established.
• Billing statements that generate after Automatic Payments are established will state that the payment amount due
will be withdrawn from your deposit account on the payment due date. Contact U.S. Bank 24hr Banking at one of the
numbers listed below to inquire on whether the Automatic Payments have been established on your account.
• Your Automatic Payment will be debited from your Deposit account on each due date. This will occur even if you elect to
make additional payments outside of the Automatic Payment or request an Automatic Payment amount that is greater than
your contracted payment amount.
• If your ACH payment is returned, you will need to make a separate payment to bring your account current.
• Your Automatic Payment Due Date will be your contractual due date.
• If your due date falls on a weekend or a holiday, the Automatic Payment will be debited from your Deposit account on the
following business day.
To cancel Automatic Payments: U.S. Bank must be notified at least three business days prior to the applicable payment date by
calling U.S. Bank 24hr Banking at the number listed below. If the Automatic Payment is not canceled in time, the system will still debit
the payment from your Deposit account. If your account received a rate discount for being on Automatic Payments, you may be
assessed an Automatic Payment cancellation fee, or be subject to a rate increase if Automatic Payments are canceled. Refer to your
original note or agreement regarding Automatic Payment discounted rates.
Any fees assessed to your account, such as but not limited to late, insufficient funds, and annual fees will be added to your monthly
payment amount which could cause your Automatic Payment to be greater than the amount indicated on the Automatic Payment
Withdrawal form. This amount will be debited from your Deposit account on your payment due date. Assessed fees and payment
amounts will be disclosed on your monthly billing statement that will be mailed at least 10 business days in advance of the Automatic
Payment date.
To change your contractual due date, please contact U.S. Bank 24hr Banking at the number listed below for assistance.
There is the potential for this account to require force placed insurance. In the event this account requires force placed insurance,
the monthly payment and monthly Automatic Payment withdrawal amount may change during the life of the loan. U.S. Bank will notify
customers in writing of all force placed insurance actions, including cancellation of Automatic Payments, and the related cost.
Line of Credit Customers with Fixed Rate Option(s): If you previously authorized a Fixed Monthly Automatic Payment amount, the
preauthorized Automatic Payment will continue to be that Fixed Payment amount, unless your minimum payment for your line portion
and all Fixed Rate Options is larger than the Fixed Automatic Payment amount indicated, in which case the greater amount will be
deducted. With a Fixed Payment, any additional funds in excess of your calculated minimum payment will be applied to your variable
line principal balance until it is zero, then to the oldest Fixed Rate Option, if any, until that balance is zero, then to subsequent Fixed
Rate Options, if any, applying to the balances and satisfying each in turn oldest to newest.
Multiple Payment Option- Fixed Rate Loans Only- Lines of Credit and Variable Rate Loans are not eligible for Bi-Weekly payments.
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Bi-Weekly Payment Option: If you select biweekly payments, please note you could be making up to 27 payments per year. Your
first biweekly payment will occur on the Payment Date indicated on front, with subsequent payments being taken every 14 calendar
days thereafter.
Conditions that may cause the Automatic Payment to be canceled on your account:
-If your Automatic Payment has been returned due to insufficient funds for three consecutive payments. A payment returned as
insufficient funds may be assessed a fee which will be added to your next scheduled payment.
-If we receive notice that your Deposit account has been closed or frozen or is an invalid number. A payment returned due to Deposit
account being closed, frozen or invalid may be assessed a fee which will be added to your next scheduled payment.
-If a Credit Insurance or Payment Protection claim has been approved and those payments are being applied to your loan account.
For any questions regarding your account or Automatic Payments, please call U.S. Bank 24-Hour Banking at
800.USBANKS (872.2657) or visit us online at usbank.com
