Platinum Federal Credit Union

AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (ACH DEBITS)

COMPANY NAME:

PLATINUM FEDERAL CREDIT UNION

COMPANY ID NUMBER:

061192274

I (we) hereby authorize PLATINUM FEDEFRAL CREDIT UNION, hereinafter called COMPANY, to initiate debit entries to my (our) Checking Account / Savings Account (select one) indicated below at the depository financial institution named below, hereinafter called DEPOSITORY, and to debit the same to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. Law.

DEPOSITORY NAME:

_________________________________________

BRANCH:

_________________________________________

ROUTING NUMBER:

_________________________________________

CITY:

_________________________________________

STATE:

_________________________________________

ZIP:

_________________________________________

ACCOUNT NUMBER:

_________________________________________

This authorization is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.

NAME(s):

_________________________________________

ID NUMBER:

_________________________________________

Signature of Member ________________________________ DATE:___________________

NOTE: ALL WRITTEN DEBIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION.

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