Customer Information

This is permission for recurring debits. As an authorized signor on the Depository Account presented, by completing and signing this form you give the Veterans’ Home Purchase Board permission to charge/debit your account for the amount indicated on 5th of every succeeding month. This authorization is to remain in full force and effect until Veterans’ Home Purchase Board has received written notification from me of its termination.

First Name *

Last Name *

Billing Street Address *

City *

State *

Zip *

Phone Number *

Email Address *

Loan Information

Loan Account Number *

Bank Information

Depository Bank Name *

Account Type *

Checking

Savings

Routing Number *

Account Number *

Electronic Signature

I acknowledge that a minimum Non-Sufficient Funds (NSF) fee of $35 may be charged by Veterans’ Home Purchase Board to me in the event there are insufficient funds available at the time the ACH payment is submitted. I authorize Veterans’ Home Purchase Board to charge/debit the account indicated in this authorization form according to the terms outlined above. I certify that I am an authorized signor on this Depository Account.

Electronic Signature *

Date * Example: mm/dd/yyyy

Veterans' Home Purchasing Board

Recurring ACH Debits Authorization Form

Customer Information

Loan Information

Bank Information

Electronic Signature