Form 3133-0135 Authorization Agreement for Electronic Funds Transfer Pa

NATIONAL CREDIT UNION ADMINISTRATION

AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER PAYMENTS

In accordance with the Debt Collection Improvement Act of 1996 (Public Law 104-134), the National Credit Union Administration (NCUA) must make payments to credit unions by Electronic Funds Transfer (EFT).

PART I – MUST BE COMPETED – Please print

NCUA CHARTER NUMBER (FCU) OR INSURANCE CERTIFICATE (FISCU) ___________________________

CREDIT UNION NAME_______________________________________________________________________

ADDRESS __________________________________________________________________________

CITY _____________________________________ __________ STATE ________ ZIP____________

EMPLOYER’S ID NO. [TAXPAYER ID NO].________________________________________________

CONTACT PERSON __________________________________ PHONE NO. ___________________

EMAIL _____________________________________________________________________________

FINANCIAL INSTITUTION NAME ______________________________________________________________

9-DIGIT ROUTING & TRANSIT NO. (RTN)_________________________________________________

ACCOUNT NO. ______________________________________________________________________

(must be at least 4 digits, and only contain numbers, spaces, or dashes)

If using a corporate credit union, please call your corporate to verify correct RTN and account info for ACH use.

PART II – OPTIONAL

As a convenience to credit unions, NCUA is now using a Treasury-developed program, Pay.Gov, to accept electronic credit union payments to NCUA via direct debit on the invoice due date using the account info above.

If you do not elect Pay.Gov as a method of payment to NCUA, you must pay NCUA invoices by check.

 Yes, please direct debit my credit union’s invoiced amounts through Pay.Gov.

PART III – MUST BE COMPLETED

I authorize NCUA to initiate electronic funds transfer payments to the credit union (and from the credit union if Pay.Gov option was elected).

This authorization replaces all previous authorizations and remains in full force and effect unless NCUA receives a new authorization, 30 days prior to the next established payment date.

NAME OF AUTHORIZED

REPRESENTATIVE____________________________________ TITLE_____________________________

Please Print Please Print

SIGNED_______________________________________________ DATE ___________________________

PLEASE KEEP A COPY FOR YOUR RECORDS.

Please complete and return to: National Credit Union Administration

By Fax to: OR By Mail to:

703-837-2400 National Credit Union Administration Office of the Chief Financial Officer

1775 Duke Street

Alexandria, VA 22314-3428

OMB No. 3133-0135 9/30/06