Complete this form, print and mail to the address below.

Elect to have your payments automatically debited from your account. With a simple form and your signature, it’s just that easy. Just fill out this application and mail it to First National Bank of America. Any questions call 1-800-266-7661 ext. 8905.

(Your account needs to be current.)


NAME______________________________ FNBA LOAN NUMBER_____________________

NAME OF YOUR BANK/CREDIT UNION ______________________________


BANK ROUTING NUMBER ___ ___ ___ ___ ___ ___ ___ ___ ___.
(For savings accounts, contact your bank for this number)

BANK ACCOUNT NUMBER_______________________________.
(A blank VOID check is required)

WHICH ACCOUNT WOULD YOU LIKE DEBITED? Checking_________Savings__________
(Should any debit be returned for non-sufficient funds there may be an NSF fee and a late fee may be incurred.)

ADDITIONAL FUNDS___________________
(If you want to pay extra each month to be applied to principal, indicate the extra amount here)

I hereby authorize First National Bank of America (FNBA) to debit my bank account for my monthly loan payment. FNBA will notify me with written confirmation and the effective date of my first automatic debit. This authorization will remain in effect until I notify FNBA in writing, three (3) business days before my due date, that I wish to cancel it,(**Remember, if your monthly escrow increases, your ACH will automatically increase**) allowing FNBA reasonable time to act upon my request. I understand that FNBA reserves the right to cancel this agreement, in writing, at any time.

Please sign here ________________________________________ Date ________________
Must be signature of person holding checking account.

Please include phone number where you can be reached during the day.
Phone: ________________________

Mail to:
First National Bank of America
Attn: Autopay
P.O. Box 980
East Lansing, MI 48226

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