Automatic Payment Plan Enrollment Form

I (we) authorize Ways to Work or its service provider to initiate a monthly deduction from my (our) account at the financial institution identified on this form for the regularly scheduled monthly payment as disclosed on the Promissory Note and Security Agreement.

The processing time for the Automatic Payment Plan Enrollment is ten (10) business days after the enrollment form is received by Ways to Work. A confirmation notice will be to me sent upon plan enrollment.

This authorization enrollment form will remain in effect until all amounts payable to Ways to Work are paid in full or until Ways to Work has received from me (us) written notification to cancel the plan.

If the payment date falls on a weekend or holiday, the payment will be deducted on the next business day.

If there are insufficient funds in your account on the payment due date, you may be charged a fee by your financial institution. You also will be charged a $15 Dishonored Item fee.

Complete and submit the Automatic Payment Plan Enrollment Form and mail the form to:

Ways to Work

P.O. Box 5920

Madison, WI 53705

ATTN: Loan Services

Name
Address / City / State / Zip
Loan Number Bank Name
Bank Address
Routing Number
$ / Account Number / Account Type
Checking – Voided Check
Savings – Savings Deposit Slip
Withdrawal Amount / Monthly withdrawal date
5th 12th 21st 28th
Attach voided check or savings deposit slip here for
verification purposes
Signature(s) of checking/savings account holder(s)
x x
Date / Date