Request for Automatic Payment

This form is to assist with setting up ACH.
*Please check with your biller to see if they require a special form.

Member Information:
Name:
Contact Phone:
Account to be Paid:
Company Name:
Account Number:
Payment Amount:	Please pay $ or %
Date to pay:
Paid From:
Financial Institution:	Northwest Community Credit Union
Routing Number:	323276524
Account Number:
Account Type:	Checking Savings
Signature:
Signature:	Please use the information I provided above to pay my bill. I understand that is my responsibility to ensure the first payment is made. If the first payment is not made using the automated process, the first payment will be made by me. X ____________________________________________________________
- - - Staple Voided Check Here - - - A voided check is required for all automatic payments.

Print and mail to the organization that bills you.