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					                                                EFT Authorization Form

I request and authorize AMERICAN CONSUMER CREDIT COUNSELING (ACCC) to automatically deduct payments from the
checking/savings account at the financial institution (bank) named on the attached voided check or savings deposit slip, and I authorize
the financial institution holding the checking/savings account to honor the deductions. I understand that these deductions will be applied
as regular payments under the signed contract with ACCC. The laws of Massachusetts govern ACCC’s EFT Authorization Agreement.
Your funds will be drawn on the 2nd or 16th day of the month, or the closest weekday prior to the weekend. ACCC reserves the right to
resubmit an electronic draft for a second time, should funds from the above-designated dates be returned as insufficient. A $10 fee will
be incurred for payments returned for insufficient funds. The funds will then be disbursed on ACCC’s next regularly scheduled
disbursement date. This process allows our clients to avoid further delinquencies with their creditors. This authorization will remain in
effect until ACCC is paid in full or until I submit a cancellation request to ACCC in writing, allowing 30 days to process th e request. I
understand that my participation is subject to approval by ACCC.

Social Security #:
ACCC Client #:_________________________________________________________________________________________________
E-mail Address:
Scheduled Monthly Payments in program: (*) $
Effective Date:
Checking Account #:
Savings Account #:
Bank Routing #:
Bank Address:
City, State, Zip Code:____________________________________________________________________________________________
Bank Phone #:

Applicant Signature: ____________________________________________________ Date: __________________________________

* Payment may change depending on individual requirements of each creditor.


•   If you want your EFT to be drawn on the 2nd of each month, your authorization form must be received by the 26th of the previous
•   If you want your EFT to be drawn on the 16th of each month, your authorization form must be received by the 10 th of that month.


•   Be aware that when an account is paid in full, the funds that were allocated to that creditor will be redistributed to a remaining
    creditor on the program, which ACCC deems will be the most beneficial to you. This ensures that your electronic withdrawal will
    remain the same until all accounts are paid in full.
•   Attach a voided check or deposit slip if mailing. If faxing, copy the voided check or deposit slip and fax to 617-244-1116,
    Attn: Disbursements.

                  130 Rumford Ave., Suite 202 Newton, MA 02466-1316 Phone: 1-800-769-3571 Fax: 1-617-244-1116 www.consumercredit.com
                                     Member of The Association of Independent Consumer Credit Counseling Agencies

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