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

Preferred Payment Date:
Name on Account (Please Print):
Address:
City/State/Zip:
Please transfer payments directly from my:	Checking account (attach a voided check) Savings account (attach a savings deposit slip)
Routing # (between these symbols |:|:):
Account Number:

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 avoided check or savings deposit slip.

**Authorized Signature on my Account: ____________________________________________ (SIGN ON LINE)

 Date: 

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