Please feel free to use the text boxes provided to type information onto this form. Please print the form, and sign the authorization.
Please Fax to: 801-208-1004
Or mail to:
American Credit Foundation
7720 South 700 East, Midvale, UT 84047

Print form

    Preferred Payment Date

    Name on account

    (Please print)

    Address

    City / State / Zip

    Please transfer payments directly from my

    Checking account (attach a voided check)Savings account (attach a savings deposit slip)

    Routing #

    (between these symbols |:|:)

    Account Number:

    I authorize American Credit Foundation to process debit entries from my account. This authority will remain in effect until I give reasonable notification to terminate this authorization or until the last specified payment date. I understand there will be a $10.00 fee automatically charged to my account for any insufficient funds (NSF) transactions. I have attached a voided check or savings deposit slip.

    **Authorized Signature on my Account:

    Date:

    ES2172 – Please attach voided check or savings deposit slip – ES2172

    FOR OFFICE USE ONLY
    Client Account#: Total Monthly Payment:
    1st payment date: Payment Frequency
    1st payment Amount: Amount collected per
    payment transferred:

    Attach voided check or savings deposit slip here

    **Please make sure you “Sign” the form before faxing

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