NDVA - SFN 58957 Authorization Agreement for Direct Payments (ACH Debits)

Name*

First NameLast Name

Loan Number (if known)

I hereby authorize North Dakota Veterans Affairs to make withdrawals from my account as specified below until the loan is paid in full.

Amount to Withdraw*

Type of Account*

CheckingSavings

Date to Withdraw*

1st15th

Starting Month*

I acknowledge that the origination of ACH transactions to my account must comply with the provisions of US law.

Financial Institution*

Branch

Address

Street Address

Street Address Line 2

CityState

Zip Code

Routing Number*

Account Number*

This authorization is to remain in full force and effect until North Dakota Veteran's Affairs has received written notification from me of its termination in such time and in such manner as to afford North Dakota Veteran's Affairs and my financial institution a reasonable opportunity to act on it.

Signature*

Date*

Date

NOTE: Debit Authorizations MUST provide that the Receiver may revoke the authorization ONLY by notifying the Originator in the manner specified in the Authorization.

Please attach a voided check (If available)

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