Power of Attorney Certification Form

P.O. Box 3211
Milwaukee WI 53201-3211
414-273-6266 Telephone
414-223-3201 Fax
800-927-2547 Toll-Free
catholicfinanciallife.org
For overnight delivery use 1100 West Wells Street, Milwaukee, WI 53233
Electronic Funds Transfer Plan Authorization for Premium Withdrawal
Instructions
1.) Please complete the following form to change the account where money is withdrawn to pay
premiums on Catholic Financial Life certificates.
After completing, please print the form for your dated signature.
2.) When returning the form, please include a blank, voided check or deposit slip. The paperwork
can then be submitted by:
a. Mailing to Catholic Financial Life at the above address.
b. Faxing to: (414) 223-3201.
c. Emailing to [email protected] (along with the voided check or deposit slip).
Certificate Number: _______________________ Insured: __________________________________
Certificate Number: _______________________ Insured: __________________________________
Certificate Number: _______________________ Insured: __________________________________
Certificate Number: _______________________ Insured: __________________________________
I/We hereby request and authorize CATHOLIC FINANCIAL LIFE, Milwaukee, Wisconsin, to draw funds
under the Electronic Funds Transfer Plan to pay the premiums on the certificate resulting from this
application. The funds should be drawn from the following account:
Name as it appears on Bank Account: ______________________________________________________________
at _________________________ of ___________________________________
Name of Financial Institution
City and State
__________________________
Routing Number (first 9
digits on bottom of check)
Account Number: ___________________________
 Checking
____________________
__________________________________
Date
Signature of Premium Payer
 Savings
_______________________________
If joint account, Other signature.
Subject to the following conditions:
1. The draw day may differ from the contract’s effective day.
2. The privilege of paying premiums under this Plan may be revoked by Catholic Financial Life if any transfer
is not paid upon presentation.
3. This Plan shall not be construed as a modification of any of the provisions of the certificates, except that
during the continuance of this Plan, Catholic Financial Life shall not be required to give notice of
premiums becoming due on any of the policies issued to the undersigned.
4. The payment of premiums under this Plan may be discontinued by Catholic Financial Life, or the
undersigned upon seven (7) days’ written notice.
IMPORTANT: INCLUDE A VOIDED BLANK CHECK OR DEPOSIT SLIP
Form No. MS-005-0610