|
SPEEDPAY
Request
Customer Name:_________________________________
Date:_______________
| Bank
Routing Number (1): ___________________ |
Bank Account Number (2):
__________________
|
Name ___________________________________________________________
Address _________________________________________________________
City, State, Zip ____________________________________________________
|
Name and Address, as it appears on
the check:
|
Name ___________________________________________________________
Address _________________________________________________________
City, State, Zip ____________________________________________________
Next check number in sequence:_______________________________
| Amount: $__________________________ |
Payment for Loan # __________________________ |
Loan in the name of :___________________________________ |
____________________________________
Authorized Signature
| Please
sign and fax to us at 305.669.6604. Checking account holder will receive
a confirmation of the SPEEDPAY transaction by mail. |
|
(1 )  This character appears before and after the Routing number.
(2)  This character appears after the account number.
|
