Authorization Agreement For Pre-Authorized Payments (Debits)

Member Name:_________________________________________________________
(Last, First, Middle)

Debit Account # (attach void check)__________________________________________
Savings       Checking

Name of Donor Institution__________________________________________________

Address_______________________________________________________________

ABA Routing Number #___________________________________________________

Deposit (Credit) Funds to Mid American Account________________________________

Mortgage Loan Installment Loan
Savings Checking


$Amount_______________________________________________________________


Effective Date ___________________________________________________________
Month/Day/Year

As a convenience to me, I hereby authorize, direct and empower the donor institution to pay and charge to my account, checks drawn on my account by my agent, the recipient institution named above, and payable to it, provided there are sufficient collected funds in said account to pay the same upon presentation. I agree that the donor institution's rights regarding each such check shall be the same as if it were a check drawn on the donor institution and signed personally by me. This authority is to remain in effect until revoked by me or the recipient institution in writing. Until you actually receive such notice, I agree that the donor institution shall be fully protected in honoring any such check.
I further agree that if any such check be dishonored, whether with or without cause and whether intentionally or inadvertently, the donor institution shall be under no liability whatsoever.

I hereby revoke the authorization referenced above.

Signature_____________________________________Date_______________________

For Office Use Only

_________________________________________________
Mid American Signature Date

Mail completed form to:
Mid American Credit Union
8404 West Kellogg Drive
Wichita, Kansas 67209