Automatic Payment Form


Name *
Name
Action
Frequency
I authorize the Credit Union to transfer funds from my account(s) with the following frequency:
Type of Account
I understand it is my responsibility to maintain a balance in my account to enable the transfer to be made on the specified date. If there are not sufficient funds in the account on the transfer date, available funds will be used to make a partial transfer in any order determined by MED5 Federal Credit Union. The transfers will continue until I notify the Credit Union in writing to cancel or update the transfer or if the Credit Union notifies me the transfer will be discontinued. The Credit Union must receive the written request for cancellation seven (7) business days prior to the transfer.