AUTHORIZATION FOR DIRECT PAYMENT VIA RECURRING ACH (ACH DEBITS)
Address Line 2
State or Territory
Apex Bank Account Number
Type of Account
Direct Payment via ACH is the transfer of funds from a Personal or Business account for the purpose of making a payment. I (we) authorize Apex Bank to electronically debit my (our) account (and if necessary, to electronically credit my (our) account to correct erroneous debits) as follows. Furthermore, I understand that depending on the conditions of my loan or if my loan includes an escrow, my payment amount may be changed to meet those conditions. In most cases, notification of these changes will be made sent via written communication before the change will take place.
I Agree to Recurring Payments
I Do Not Agree to Recurring Payments
Checking Account / Savings Account / Business Account (select one below) at the depository financial institution named below (“DEPOSITORY”). I (we) agree that ACH transactions I (we) authorize, comply with all applicable law.
Names(s) on the Account
Recurring Payment Amount to be Drafted
Date(s) to Transfer
Frequency of Debit(s) (Monthly / Weekly / Etc.)
Customer Digital Signature (1)
Customer Digital Signature (2) If Applicable
By marking the check box below, I (we) do hereby authorize Apex Bank to set up this automated ACH and understand that this authorization will remain in full force and effect until I (we) notify Apex Bank in writing by mail to P.O. Box 549, Camden, TN 38320 that I (we) wish to revoke this authorization. I (we) understand that the Apex Bank requires at least 5 days prior notice in order to cancel this authorization. Furthermore, I verify that the names and information provided in this form are true and understand that falsification of information can be punishable by law.
I Do Not Agree
Please double check all information before clicking submit to help avoid any potential issues which could result in delaying the processing of your request. If you have any questions or run into any issues completeing this form, please contact us at 877-226-5361 during regular business hours.
If you would prefer to print this form out and send it to us via the mail or fax, please
. Our mailing address is 430 Montbrook Lane Suite 207-208, Knoxville TN 37919 and our fax number is (865) 531-4975.