Bank Acct. Number: 323396364
Bank Acct. No. Check No. ABA Routing Number: Account Number: This is a checking account* savings account**
Bank Acct. Information:
Bank Acct. No. Check No. Bank Account Holder(s)*: Bank Name: Bank Address: Bank Phone Number: ABA Routing Number: This is a checking account savings account** Account Number: *Note: The person completing and signing this authorization must be the bank account owner. **If a savings account is identified above, please send your bank’s routing number and your savings account number on bank letterhead. Authorization: By signing below, I (we) hereby authorize DLL Finance LLC (“Originator”) (whether acting alone or through its servicer or any agent on its behalf) to initiate withdrawals from my (our) account provided above for amounts then due under my agreements with Originator in the frequency (i.e., monthly, quarterly, etc.) as specified in my (our) agreements with Originator. This authorization will remain in full force and effect until the agreements are paid in full or this authorization is canceled by written notice from me (or either of us) to Originator. Account Holder Account Holder Signature: Signature: Print Name: Print Name: Print Title (if applicable): Date: Print Title (if applicable): Date: Please send this completed and signed form and a copy of a voided check to our Customer Service team by mail, email or fax to: Mail: Fax: Email: Questions? Call us:
Bank Acct. Number Bank Routing Number (nine digits) Day of month 15th of the month only Amount to Draft $ or Full Amount Name of Depository Financial Institution City State Zip Date SIGNED
