Check By Phone Loan Payment Request Form

Checkless Loan Payment Request Form
1. Whose loan is being paid?
Member or co-borrower’s name ________________________________________________
Member number ____________________________
Loan number ________________
2. Where will the payment be coming from?
Financial Institution: ______________________________
City, State: ______________________________________
Name on Account: ________________________________
Routing Number: _________________________________
Account number: _________________________________
3. Are you the person whose loan is being paid?
No, my name is __________________________________________________
My address is ___________________________________________________
My city, state and ZIP are __________________________________________
4. How much should we withdraw from the checking account above?
Loan payment amount (no principal only payments or payoffs)
Checkless Loan Payment Fee
Total to be withdrawn
5. How can we get in touch with you?
Day or cell phone number _______________
Email: _______________________________
6. Please review and sign our Authorization Agreement:
I hereby authorize and request Hanscom FCU to initiate an electronic debit entry from my account at
the financial institution listed above to the Hanscom FCU loan listed above in the amount shown as
Total to be Withdrawn. I acknowledge that a fee of $5.00 is being applied to process this Checkless
Loan Payment request. I understand that the loan payment will be posted when you receive funds
from the financial institution listed above, usually 1 to 2 business days after receipt of this request.
Signature: _______________________________________
Date: ______________________
Please return this form to us by fax at 781-274-0239 or 888-279-7725, or in person at any branch.
You can avoid the Checkless Loan Payment Fee by setting up a recurring transfer from your other
financial institution with Easy Transfer. This free service takes the worry out of transferring the same
amount on the same date each month. To sign up, download the Easy Transfer form here: