WP E-Signature by Approve Me - Sign Documents Using WordPress -

Automatic Payment Authorization Form

Instructions

1) Provide all required (*) information so we can effectively process your request.
2) Your email address and electronic signature are required to securely complete this request online, and a copy will be sent to your email address after you "Agree & Sign".
3) A phone number is required to contact you if we're unable to identify your account information.
4) If it is your first time setting up automatic payments, please select “First Time Automatic Payment” below. If you have an existing automatic payment, and need to change your banking information or payment amount, please select “Change to Existing Automatic Payment” below.
5) By completing my electronic signature, I authorize BCI Financial to debit my checking or savings account for all future payments to my BCI Financial loan account. I understand that I may cancel this request only with ten (10) days written notice. I understand that I am responsible for any overdraft fees that may occur as a result of this transaction. This service will continue until either the BCI Financial loan account is paid in full or until it is cancelled by you or BCI Financial. The payment will occur monthly on the payment due date or the first business day following the payment due date.

* Request Type (select one): First Time Automatic PaymentChange to Existing Automatic Payment

* BCI Financial Account Number:

* Borrower 1 Name: Borrower 2 Name:

* Address:

* City: * State: * Zip:

* Payment Amount: * Phone Number:

* Bank Name:

Bank City: Bank State: Bank Zip:

* Bank (ABA/Routing) Number: * Bank Account Number:

* Bank Account Type (select one): CheckingSavings

Leave this empty:

Your legal name