Member Services Request

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ONE TIME ACH PAYMENT AUTHORIZATION

Sign and complete this form to authorize Lifetime Federal Credit Union to make a one time ACH debit to your checking or savings account to fund a new account with Lifetime Federal Credit Union.

By signing this form, you give us authorization to debit your account for the amount indicated on or after the indicated date. This is an authorization for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account.

I, Your Name *, authorize Lifetime Federal Credit Union to debit my account indicated below for $Amount * on Date* This payment is to be deposited to my account at Lifetime Federal Credit Union as an opening deposit.

Billing Information

• Address*
• Address Line 2
• City *
• State *
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• Zip *
• Email *
• Phone # *

Account Information

• Account Name*
• Bank Name*
• Routing Number*
• Account Number *