To Whom It May Concern at, United Neighborhood Federal Credit Union

You are currently withdrawing $ __________________for my/our account number _________________________________________
                                                                                                                                        (company or payee account#)

for my/our account number _________________________________________. This payment is currently being taken from my/our
                                                        (what payment is for)

 account at ___________________________________________________________
                             (name of bank or other financial institution)

Please route my automatic payment per my instructions to the financial institution indicated below:
United Neighborhood Federal Credit Union
1434 Poplar Street
Augusta, GA 30901

Street Address State
City Zip
Cell Phone E-mail
Day Phone Evening Phone
I authorize my automatic payment to be debited:_____Monthly_____Weekly_____Bi-Weekly
Beginning Date:_________________________                 Stop Date:_________________________              From ____ Checking ____ Savings
From ____ Checking ____ Savings

   Member Signature


   Credit Union RepresentativeDate

This form goes to the company or payee.
A signature is needed to complete the process