Credit Union Mortgage Association, Inc. AUTOMATIC MORTGAGE
PAYMENT AUTHORIZATION
Instructions: Complete the Authorization form below and make a copy of the completed Authorization form for your records. If you are using a checking account
for Automatic Debit, you must send a voided check from the account you wish to be debited. If you are using a savings account, you must send a pre-printed
savings deposit ticket that includes the ABA number and your account number. Failure to do so may result in the rejection of your payment entries. If you wish to
receive a coupon book, simply mark “Decline”, sign and date the form and return it to us at 10800 Main Street, Fairfax, VA 22030.
Check One: New Change Cancel – effective ___\___\___ (Cancellation request must be received at least 10 days prior to the next transaction date)
Decline ACH – Please send me a coupon book instead of enrolling in ACH
Name
Mortgage Loan Numbe
r
Daytime Phone Numbe
r
I hereby authorize Credit Union Mortgage Association to initiate debit entries to the Financial Institution listed below, and if necessary initiate credit entries or
adjustments to correct a debit entry originated in error, to make my loan payment for the amount specified on this authorization. I understand that my automatic
payment will be adjusted automatically if my payment changes due to escrow analysis and/or adjustable rate. Payment dates that fall on non-business day or
holiday will be processed the following business day. Payments returned will be reversed and will not be resubmitted. A $15.00 return item fee will be assessed for
all returned payments. I understand that Credit Union Mortgage Association is not responsible for any fees, penalties or late charges. Repeated returned payments
will result in termination from the program. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. Law.
Drafts will occur on the 7
th
day of the month.
Optional: In addition to my regular payment, please deduct an additional $___________________ each month and apply to principal.
Start Date: _____ / _____ / _____ (We must receive this authorization at least 15 days prior to the start date.)
Depository Institution
A
BA Number (Routing Number)
City State Zip Institution Phone Numbe
r
Name on Account Account Numbe
r
Choose One
Checking Savings
This authorization is to remain in full force and effect until Credit Union Mortgage Association has received a written request to terminate this authorization in such
time and in such manner as to afford Credit Union Mortgage Association a reasonable time to act on it. By signing below, I agree to the terms and conditions
specified within this authorization.
Borrower’s Signature Date
A VOIDED CHECK OR PRE-PRINTED SAVINGS DEPOSIT TICKET MUST BE ATTACHED TO INITIIATE YOUR AUTOMATIC PAYMENT.
Please fax to (703) 425-7089 or mail the completed form with attachments to:
Credit Union Mortgage Association
10800 Main Street
Fairfax, VA 22030
If you have any questions, please contact Loan Servicing at 800-231-8855.
INTERNAL USE ONLY
Date Received: _______ \ _______ \ _______ Received By: ___________________
Date Processed: _______ \ _______ \ _______ Processed By: __________________ Entered: MS Confirmation Sent
