TopLine FCU | Automatic Payment Authorization Form

Never miss a payment with our automatic loan payment service.

Complete the form below, and click the print button to print out the completed application. Please mail the form, along with a voided check or deposit slip:

TopLine Federal Credit Union
ATTN: New Accounts Department
9353 Jefferson Highway
Maple Grove, Minnesota 55369.

Automatic Payment & Coupon Authorization:

Note: This form is for loans held at other financial instituitions.

If you wish to set up automatic payments for a TopLine loan, click here.

General Information
Start Date	1st 10th 15th 20th
Starting Month
Member Name
Member Number
Phone (Home)
Phone (Work)
Address
City/State/ZIP	/ /
Payor (From)
Name
Account Number
Account Type	Savings Checking
Payment Amount
Payee (To)
Routing #
Name on Account
Account Number
Payment Amount
I authorize TopLine Federal Credit Union to initiate entries on the account listed above. This authority will remain in effect until I notify you in writing to cancel it in such time as to afford the financial institution a reasonable opportunity to act on it. I can stop payment on any entry by notifying my financial institution three (3) business days before my account is charged. Once payment has been stopped, it cannot be started again.


Signed Authorization

Date

Please attach a voided check or deposit slip.

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