Member FDIC - Equal Housing Lender

Privacy Statement

Recurring Transfer Request 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)

This form is to be used to set up recurring transfers.  One-time transfers can be completed through online banking.

I wish to:
Account to be Debited
Account Number:
Loan Type:
Account to be Credited
Account Number:
Account Type:
Transfer Details
Amount to be Transferred:
First Transfer Date:
Frequency of Transfer:

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.