Member Name*: / Amplify Federal Credit Union Account #*: / Date:

I hereby authorize Amplify Federal Credit Union to initiate the recurring ACH entries described below. If this authorization is for a recurring loan payment, I acknowledge that I must keep making my payments as usual until I receive confirmation from Amplify Federal Credit Union that this recurring transaction has been initiated. PLEASE NOTE: By authorizing this transaction, you are confirming that you are legally authorized to execute transactions on the designated account at the other financial institution.

Amplify Federal Credit Union Information:

Transfer from Account (Debit): / Savings Checking
Transfer to Account (Credit): / Savings / Checking
Amount*: / Post/Due Date: / Stop Date:

External Bank Information:

Institution Name*:
Address:
City, State, ZIP:
Account Holder Name:
Account #:
Routing/Transit #:
Transfer from Account (Debit): / Savings / Checking
Transfer to Account (Credit): / Savings / Checking / Loan

Frequency:

W – Weekly / BW – Bi-weekly / SL – Semi-monthly last (15, last)
Mn – Monthly on Day n / ML – Monthly on Last Day / Q – Quarterly
A – Annually / O – One time

This authority is to remain in force until I notify Amplify Federal Credit Union in writing or by phone of any changes or cancellation of payment unless such notice is received not less than seven calendar days prior to the transaction date. Amplify Federal Credit Union retains the right to cancel this service at any time. I agree to be bound by the ACH Operating Rules and all pre-arranged transactions are subject to applicable provisions of Amplify Federal Credit Union’s electronic funds transfer agreement, a copy of which has been given to me.

Member’s Signature / Date
New / Change* / Delete*

* This information is required for DELETE requests. Delete and change requests CAN use Commercially Accepted Identification Procedures.

Please send Form To: Amplify Federal Credit Union, P.O. Box 85300, Austin, TX 78708 or FAX: (512) 491-1011 or

Credit Union Use Only:

Rcvd By / Operator # / Identification Used (required)**
Support Services Rep/ Operator # / ACH Authority # / Date Loaded in System

**Indicate DL state/number, passport number, etc. If this is a phone request, please indicate method used to positively ID member; i.e.: SSN & DOB

Revised 12/15/14

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Amplify Federal Credit Unionpo box 85300austin texas 78708phone 512.836.5901toll free 800.237.5087www.goamplify.com