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Ach Debit program - Automatic withdrawal process
to assure your payments are made on time.

If you should have any questions or problems regarding this form, please call us for assistance at: (800) 510- 8765.

Fill out the following form, and your payment will be automatically withdrawn from your checking account each month. A small $5 monthly administrative fee will be added to your debit payment for the duration of the program.

Important: In addition to electronically submitting this form, you must sign and date your printed page and FAX to United Financial Systems, Inc. Please fax a printed copy to:

Fax Number
Main Office - (954) 252-2109

We must have a signed copy on file in order for you to participate in our program.

Printer Friendly ACH Form. (Black & White)

Client I.D. #:
Name on Account:
Street Address:
City:
State:
Zip:
Banking or Savings Account Information
Is this a Check or Savings Account?
Name as it appears on account:
Street Address - as it appears on account:
City, State, Zip - as it appears on account:
Routing #: The first set of numbers between these two symbols l:l:
Account #: The second set of numbers on bottom of checking or savings deposit slip.
Date of First Payment: This date will be a FIXED date every month.
Payment Amount $:
In our example check to the right, the first set of numbers is the routing number. Our example routing numbers shown are: " 012345678 " In our example check to the right, the second set of numbers is your account number. Our example account numbers shown are: " 901234567890 " The last set numbers shown on our example check is the check number. Our example check shows "1234" as being the "check number". These numbers are not necessary for us
Authorization Area
I authorize United Financial Systems, Inc. to process debit entries from my account. This authority will remain in effect until I give reasonable notification ( 30 days ) to terminate this authorization, or until the last specified payment date. I understand there will be a $25 fee automatically charged to my account for any insufficient funds (NSF) transactions.
______________________________________ ___________
Authorized Signature on Account Today's Date
Important: You must print and sign this page in Addition to submitting this form. Step 1: Please print this page prior to submitting. Step 2: Submit form electronically, and fax printed copy with signature to: (954) 252-2109.

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Debt Consolidation | Credit Counseling | Debt Management

Ach Debit Program

Payments Made Easy!

Ach Debit program - Automatic withdrawal processto assure your payments are made on time.

Ach Debit program - Automatic withdrawal process
to assure your payments are made on time.