Automatic Credit Card Payment Authorization Form

I hereby authorize Metro Medical Credit Union to initiate debit entries to the financial institution named below to automatically pay my Metro Medical Credit Union Visa Credit Card listed below. The Auto Pay draft is pulled on the 25th day after each billing cycle. I understand this Auto Pay draft will be credited to my account even if I make a manual payment.

I authorize you to debit the financial institution account listed below.

I authorize you to pay my Metro Medical Credit Union Visa Credit Card listed below.

This authorization is to remain in force until I notify Metro Medical Credit Union in writing of any changes or cancellation of payment. I understand that to change or cancel any future transactions, such notice must be received not less than three (3) business days prior to the transaction date. Metro Medical Credit Union retains the right to cancel this service at any time. I agree to be bound by the Automated Clearing House (ACH) Operating Rules and all prearranged transactions are subject to applicable provisions of Metro Medical Credit Union’s electronic funds transfer agreement and the accompanying disclosure. I also understand that if funds are not available for this transaction and the payment is returned unpaid, I will be charged the current Metro Medical Credit Union charge for returned checks and this authorization will be revoked. If the payment is returned unpaid, the Credit Card Processor will also charge the current non-sufficient payment charge.

MEMBER SIGNATURE & DATE:

MEMBER SIGNATURE REVOKING AUTHORIZATION & DATE: