PDF AUTO DEBIT AUTHORIZATION - Citizens Bank

AUTO DEBIT AUTHORIZATION

By using Auto Debit offered through the above named Bank ("Bank"), your monthly payment selection will be automatically deducted from an account you designate on the payment due date specified in your sales contract, lease contract, consumer promissory note, loan note or line of credit agreement ("Contract"). Please fill out all fields and read the form carefully. If this form is incomplete or filled out incorrectly, it will be returned to you. Information contained on this authorization form will be used by the Bank and your financial institution to complete the enrollment process. It may take up to two statement cycles for automatic payments to take effect. Please continue to make any payments that are due in the interim, as you normally would, until you see the Auto Debit appear on your debiting account statement or you receive confirmation of the set up. Please note that your account must not be past due when you request Auto Debit. If you make additional payments towards your account in advance of your due date, please note that your Auto Debit payments will continue to draft from your checking or savings account as instructed. If, for any reason, Citizens is unable to deduct payments from your account, you will still be required to remit your monthly payment amount.

If your payment is returned unpaid, you may be charged a fee for the transaction.* You authorize us to make a one time electronic fund transfer from your account to collect a fee. The fee will be determined by the contract. Your final payment will draft for the final billed amount, which may include any fees accrued, in accordance with your contract, over the life of your agreement.

CUSTOMER INFORMATION

LOAN/LINE OF CREDIT ACCOUNT NO.

FINANCIAL INSTITUTION INFORMATION

FINANCIAL INSTITUTION NAME

CUSTOMER NAME

ADDRESS

STREET ADDRESS

NAME(S) ON WITHDRAWING ACCOUNT

CITY

FINANCIAL INSTITUTION (debiting checking or savings) ACCT. NO.

STATE, ZIP

FINANCIAL INSTITUTION ROUTING NO. (9 DIGITS)

Auto Debit is not accepted for amounts less than minimum monthly payment due under the contract and only one auto debit is permitted per month.

Verify with your financial institution that your savings account may be used for "Auto Debit". Certificates of Deposit (CDs) and credit cards cannot be used with this feature.

By signing below, I authorize the Bank and its successors and assignees to automatically deduct from my checking or savings account indicated above the amount indicated under payment selection, until (1) all payments required by the contract have been made or (2) Citizens has received notification from me to terminate the Auto Debit plan, according to the instructions and

pursuant to the conditions listed above. I acknowledge and confirm that I am an authorized signer on the bank account from which I am making payment. Please refer to the reverse side of this agreement for important disclosure information and for details of how to cancel auto debit.

PAYMENT SELECTION:

Regular Billed Amount

Regular Billed Amount plus additional principal payment

Additional Principal

$

Regular billed amount may vary depending on terms of your contract. By selecting an additional principal amount, your additional payment will be applied as a principal payment. You will continue to have your account debited every month.

ACCOUNT HOLDER'S SIGNATURE:

X

BANK COPY

DATE

*Important Notice: By selecting "Regular Billed Amount plus additional principal payment", we will draft two transactions from the Financial Institution Acct. No.(1) for your Regular Billed Amount and (2) for your additional principal payment. The order in which these transactions occur will be determined by your financial institution. Should you have insufficient funds to cover both transactions, you may be charged multiple fees as each transaction is considered a unique payment.

Important Auto Debit Disclosure Information

Cancellations by you/customer: To cancel or stop payment of a preauthorized Electronic Funds Transfer (EFT)/Automated Clearing House (ACH) transaction, you must notify us three or more business days before the scheduled transfer. If notice is provided less than three days before the scheduled transfer, the EFT/ACH transaction may be paid. You may notify us in writing or provide verbal instructions by calling us at 800-708-6680 Cancellations by us/Bank: We may choose to terminate this agreement for any reason without notice. Confidentiality: We will only disclose information to third parties about your account or the transfers you make: 1) when it is necessary to complete transfers; 2) to verify the existence and condition of your account for a third party, such as a credit bureau or merchant; 3) to comply with government agency or court orders; or 4) if you give us written permission. Additional Principal Payments: If you wish to make a one-time additional principal payment to your loan aside from the payment selection above, mail the principal payment to the address on your statement. Please include the payment ticket that is at the bottom of the statement and indicate "principal payment" or "principal only" on your check. Important: If your account has a past due balance or a balance owed, these may be satisfied first.

If you reside in RI, MA, NH, CT, VT, NY, PA, MI, OH, or DE, you may also make a principal payment at one of our branch locations. You may also make principal payments by calling us at 800-708-6680 or by visiting our website.

Contact Us: If you have any questions, please contact us at 800-708-6680; we're available 24 hours a day, 7 days per week. Or you may write us at: Citizens Bank Consumer Loan Servicing JCB210 P.O. Box 42002 Providence, RI 02940-2002

CON-CO-LS-AUDB - Dec 2018

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