ACH Origination for Loan Payment – Form …

1 ACH Origination for loan Payment form Instructions Complete the form , print and send it back to USECU with a voided check. Upon receipt of the form , we will complete a Call Back Verification prior to initiating the ACH Origination . Documents can be returned to USECU by: Fax: 858-795-6034 Mail to: USE Credit Union Attn: Member Service Center 10120 Pacific Heights Blvd Suite 100 San Diego, CA 92121 Bring documents to one of our USECU branches. 10120 Pacific Heights Blvd., Ste. 100, San Diego, CA 92121 Phone: ACH Origination authorization agreement USECU loan Payment I hereby request and authorize USE Credit Union ( USECU ) to initiate, change or cancel, as applicable, debit entries from my account at the Depository Institution to be credited to the identified USECU loan as described below. New Request Change/Update CancelFROM: Depository Institution Name Phone Number Routing Number (must be 9 digits) Savings Checking (please attach a voided check) Account Number TO: USE Credit Union Membership Number loan ID Start Date Amount $ Frequency Monthly Semi-Monthly* Weekly on Friday *For semi-monthly select two days (not 29, 30 or 31): _____ and _____By signing below I confirm I have the authority to authorize debits from the Depository Institution described herein and I understand and agree to the following terms and conditions.

2 This authorization will remain in full force and effect until written notification of cancelation is given to USECU at theaddress listed above allowing USECU a reasonable opportunity to act (minimum 5 business days prior to debit entry), or until the loan is paid off (if detected). USECU reserves the right to cancel this agreement /transfer at its sole discretion for situations including but not limited to NSF, returned payments , security/fraud concerns, etc. If the ACH credit is for a USE loan Payment , be sure to update these instructions with the new Payment amount. Loanfees may apply if minimum payments are not made timely. USECU reserves the right to change the ACH transfer amount if loan payments change in accordance with the loan agreement . Debits may continue even after the loan is paid in full until you notify USECU in writing 5 business days prior to the scheduled debit . A new USECU savings share may be opened, if necessary, to receive funds.

3 If the transfer date falls on a weekend or holiday, the transfer may take place on the scheduled date, or the businessday immediately after. USECU relies on information provided on this form and is not responsible for incorrect information or changes toinformation including account numbers. Further, financial laws and regulations permit institutions to rely solely on account numbers and routing/transit (ABA) numbers for identification purposes in funds transfers including ACH activity. USECU shall not be responsible for any act, or failure to act on their part, except in the case of gross negligence orwillful misconduct. I agree to hold USECU harmless for any fees I may encounter from the Depository Institution and from any claims, liabilities, attorney s fees, and other costs resulting from this ACH Origination authorization . If necessary, adjustments and/or corrections for any entries may be Member Name (Please Print) Signature Date Date: Credit Union Use Only Teller#: Branch/Dept# Federally Insured by NCUA Account Owner Name (Please Print)DateSignature USECU loan AutoPay form