Automatic Payment Authorization Form -
From External Account

Use this form to set up automatic payments from an existing account to pay your Harborstone loan. In order for your automatic payments to be set up, this form must be accurately completed.


Request Is For

I authorize Harborstone Credit Union to transfer funds from my account listed below and apply them as a payment to my Harborstone Credit Union loan. Payments cannot be made from a military allotment.
Harborstone Loan Type
Loan Number
Debit From Account Type
Account Number
Name of Financial Institution
Routing/Transit Number

Date of First Transfer
  Harborstone Credit Union requires five days' notice prior to first payment.
Amount To Be Transferred
Frequency Of The Transfer

I make this authorization subject to the following conditions:

  1. Debits will be made based on the nine-digit routing number provided by me to Harborstone Credit Union.

    It is my responsibility to provide Harborstone Credit Union with the correct account number and routing number of the other financial institution.

  2. I have the right to terminate this authorized debit at any time by notifying Harborstone Credit Union in writing at least three business days prior to the transfer date.

  3. Harborstone Credit Union, after three consecutive months of failing to receive payment electronically, may opt to terminate this authorization.

  4. If an attempt is unsuccessful or there are insufficient funds, I am responsible for other payment arrangements.

  5. When the debit date falls on a weekend or holiday, the debit will occur on the next business day.

By signing this form, I acknowledge the terms of this agreement. I also certify that I am the owner the account being debited and that the account numbers I have provided are accurate. I understand that if the information I have provided is inaccurate, there may be a delay and the possibility of crediting the wrong account.

You are signing this form electronically, and in doing so, you agree your electronic signature is the legal equivalent of your handwritten signature.

Name
Email Address
Phone Number

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