Member FDIC - Equal Housing Lender

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Loan Payment Transfer Form
Submitter Information (Required)
First Name
Last Name
Resolve the errors marked in red before submitting again.
Contact Information
Phone Number:Email Address:

Mailing Address

We will not update our records with this information. If this information needs updated, please submit an "address/contact change form".

Contact Preference
If we have questions about this form, how would you like us to contact you? (required)
I wish to:
Loan Details
The loan account number is:
Loan Type:
Account to be Debited for Payment if a Farmers Account
Account Number:
Account Type:
Account Information for an Account being Debited at Another Financial Institution
Bank Name:
Routing Number:
Account Number:
Type of Account:

Please note: Your monthly payment amount may change for escrow amounts or lines of credit.

Payment Information
Amount to be transferred:
If the option selected above to add additional principal; list the additional principal payment to be added:
Please list any additional details:

By submitting this form, I hereby authorize the Bank to make the transfer(s) indicated above until further notice from me.  If this agreement changes any prior authorization between you and the Bank, the prior authorization is hereby cancelled, and I instruct you to follow this authorization.  I acknowledge that I have reviewed an Electronic Funds Transfer Disclosure Statement which describes your and the Bank’s rights and responsibilities concerning the above transfer(s), and that it is incorporated by reference into this authorization agreement.  I further acknowledge that you have no responsibility to contact me when the above transfer(s) occur(s).  I understand that I can call you to find out whether or not the transfer has been made.  I understand that it is my responsibility to have sufficient funds available in my account on the transfer date(s) in order for you to make the automatic transfer(s).  If sufficient funds are not available in my account to cover the amount of the transfer(s), the transfer(s) will not occur.  I further acknowledge that the Bank will not be liable for any charges, including but not limited to any charges related to items being returned because of insufficient funds, any late charges or additional interest accruing on a loan.