FirmAuto USA Inc.

18000 Studebaker Rd. Suite 700

Cerritos, CA, 90703
Customer Service Phone: (855) 490-0900
firmautousa.com

______________________________________________________________________________

ACH ORIGINATION INCOMING

AUTHORIZATION AGREEMENT FOR PREAUTHORIZED DEPOSITS
OR LOAN PAYMENTS TO LENDER

As a convenience to me, I hereby request and authorize Lender, herein called Lender, to
initiate withdrawal entries from my account at the LENDING INSTITUTION indicated
below, in order to establish automatic transfer of funds, and if necessary,
adjustments for any entries in error, to my Lender account as indicated below. I also
authorize the LENDING INSTITUTION indicated below to withdraw the same from such
accounts. I agree that Lender’s rights in respect to each transfer of funds shall be the
same as if it were a draft/check drawn on the LENDING INSTITUTION indicated below
and deposited to my account at Lender and personally endorsed by me, and Lender shall
be fully protected in honoring such transfer. If the transfer date falls on a weekend or
holiday the deposit/payment will take place on the prior business day. I acknowledge
that the origination of ACH transactions to my account must comply with the provisions
of United States law.

(Check One) New ( ) Change ( ) Cancel ( )

FROM ACCOUNT:
Bank Name

Bank Routing (ABA) Number

Bank Account Number

Savings □ Checking □ Weekly □ Bi-Weekly □ Monthly □

Authorizing Signature:

Date:

Printed Name:
 FirmAuto USA Inc.
18000 Studebaker Rd. Suite 700
Cerritos, CA, 90703
Customer Service Phone: (855) 490-0900
firmautousa.com

______________________________________________________________________________

ATTACH VOIDED CHECK HERE:

NOTE: DEBIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE
AUTHORIZATION ONLY BY NOTIFYING LENDER IN WRITING. THIS FORM MUST BE
SIGNED BY THE CUSTOMER.

TO ACCOUNT:
Lender Name FirmAuto USA Inc.

Member Name:

Loan Number:

Bank Name Bank of America

Bank Routing (ABA) Number 121000358

Bank Account Number 325108007350

TO BE COMPLETED BY LENDER:
By: Process date:

Name: Today’s date:

Title: