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ELECTRONIC PAYMENT SERVICE DEBIT AUTHORIZATION AGREEMENT

Please call 587-2700 if you have any questions about completing the
Electronic Payment Authorization Agreement.
Requirements:
  • Monthly recurring debits (no utility payments)
  • $100 in your Regular Share Account
  • Account established at another financial institution. You must be the account holder at the financial institution receiving the withdrawal and be the one to sign the Electronic Payment Service Debit Authorization Agreement
  • Withdrawals from personal accounts only
  1. Name - Your name.
  2. HSFCU Account Number - Your account number at HSFCU.
  3. Current Date
  4. Please read the agreement carefully before signing. Sign and date the form, and please give us a phone number where you may be reached during the day in case we have to contact you.
  5. Name of Bank, S&L or Credit Union - The name of the other financial institution.
    Branch - Branch name.
    City, State, Zip - City, State and Zip where branch is located.
    This information is necessary in case we have to contact the other institution.
  6. Type of Account - Check the appropriate box for either checking or savings at the other financial institution; ONLY ONE (1) may be selected. If you wish debits from both checking and savings, please submit separate Authorization Agreements for each type of account even if they are from the same institution. Each transaction will be handled separately.

    For debits from your checking account, please submit a voided check or photocopy of a check. If a voided check is submitted, please write "VOID" across the face of the check making sure that the printed line on the bottom of check is legible. The credit union has to be able to verify the numbers on the printed line.

    Example:

    123456789 1234-567891 1234
  7. Account Number - Your account number at the other institution from which the funds will be withdrawn.
    Please be sure that the number is legible.
  8. Payment Date - Select one of the payment dates offered
  9. Amount of Payment - Enter the dollar amount for the monthly automatic withdrawal.
  10. Application of the Payment -
    • Enter the name of the account holder if not your account.
    • Enter the account number(s) and sub-account(s) to which the funds are to be credited
    • Enter the dollar amount to be credited to the sub-account(s)
  11. Print 2 copies (retain 1) for your records
  12. Sign and mail the agreement with a voided check to:
Hawaii State Federal Credit Union, Attn: Webmail, P.O. Box 3072, Honolulu, HI 96802-3072

Authorization for Electronic Payment Service (Debit)
I authorize the Hawaii State Federal Credit Union (HSFCU) to automatically deduct payments from my account at the financial institution indicated below and on the payment date selected. I acknowledge that the electronic payment transactions must comply with the provisions of U.S. law. I also acknowledge that this authorization is to remain in effect until HSFCU receives my written cancellation in such time and manner as to afford HSFCU reasonable opportunity to act on it; and that HSFCU retains the right to cancel this authorization at any time and a new authorization must be submitted to reinstate the service. I understand that I am responsible for any loss or penalty that I may incur due to Non-Sufficient Funds or other conditions that may prevent the withdrawal of funds from my account at the financial institution indicated below. I also understand, that if the payment date falls on a weekend or holiday, the payment will be deducted from my account on the last business day before the weekend or holiday.

_______________________
Signature

HSFCU Account Number

Date

Name

Daytime Phone

E-mail Address


Name of Bank, S&L or Credit Union and branch location

City, State, Zip


Account Number
Checking Savings
Type of Account
$
Amount of Payment

Start Payment on (date)

Select One Payment Date
1st 5th 7th 10th 15th 20th 22nd End of month
Please apply the payment as follows:
Account Name
(if not your own)
Account Number Share Account # Loan Account # Payment Amount