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
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.
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
Attach voided check or savings deposit slip here
**Please make sure you “Sign” the form before faxing
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