ACH Recurring Authorization Agreement for Electronic Payment Form

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Form Instructions

For loan payments, please use our Pay from an Outside Account service.

Please print this form, then sign, date and fax it to (408) 543-5203, Attn: Support Services, or mail it to:

Star One Credit Union
Attn: Support Services
P.O. Box 3643
Sunnyvale CA 94088-3643

Your Information

Member Name:
Member Number:
Telephone Number:

General Information

	This is a new authorization
	Change an existing authorization
	Cancel an existing authorization

Effective Date:

Transfer Type

Transfer to Star One CU from my personal account at another financial institution.

	Savings
	Checking

Transfer from Star One CU to my personal account at another financial institution

	Savings
	Checking

Transfer Information

Transfer Frequency:

	Monthly
	Biweekly
	Weekly

Day/Date of Transfer
(funds will transfer one business day earlier when selected date falls on a weekend or non-business day):

Transfer Amount:

Other Financial Institution Information

Name on the Account:

Financial Institution Name:

ABA/Routing Number:

Account Number:

Account Type:

	Savings
	Checking

I authorize Star One Credit Union to originate Electronic Funds Transfer transactions between the Credit Union and the other Financial Institution indicated above. This authorization is to remain in full force and effect until the CREDIT UNION receives my WRITTEN NOTIFICATION of its termination at least (3) three business days before the scheduled date of transfer in order to be effective. This authorization must be provided to the Credit Union at least 5 business days before a new or existing payment takes place. A $ 15.00 fee will be charged to the above Credit Union savings or checking account for each item returned. The Credit Union may terminate this agreement if the Credit Union receives (3) NSF's for the same account number or otherwise if I fail to comply with my Membership and Account Agreement. A one-time set-up fee of $5.00 will be charged for each new outgoing request.

I further acknowledge that any electronic fund transfers initiated will not violate provisions of U.S. Law, including the requirements of the Office of Foreign Asset Control (OFAC). Some restrictions apply; all requests are subject to approval.

___________________________________________
Member Signature

_______________________
Date

Star One Credit Union use only
Received by (Initial and Teller#):		Date:
Processed by (Initial and Teller#):		Date:
Verified by (Initial and Teller#):		Date:

Rev: 06/19/2017

ACH Recurring Authorization Agreement

Form Instructions

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