Download MODERN FINANCE now offers direct withdrawal from your checking

MODERN FINANCE now offers direct withdrawal
from your checking account!
No more writing checks, looking for stamps or wondering if your payment will make it on
time!
Just provide us with your checking account information, and Modern Finance will
automatically withdraw your monthly payment from your checking account!
Simply, fill out the form below and mail a copy of your check or voided check to us.
Please note that we will need at least 10 days advance notice before your due date in order
to set up your account.
Please return the section below along with copy of check to Modern Finance:
…………………………………………………………………………………………………………………………………………….
I authorize Modern Finance Company and the financial institution I have indicated to deduct from my
checking account monthly payments for my auto contract. I understand that my checking account will be
debited for the amount shown due on my monthly bill. I understand that if my payment transaction is
returned for any reason, including insufficient funds or a closed account, a $15 return check charge will be
added to my Modern Finance account. I understand that I must notify Modern Finance if I want to
discontinue this service 3 business days before my scheduled debit date.
Name on Modern Finance account_________________________
(Nombre de la cuenta con Modern Finance)
Modern Finance account number ________________________
(Numero de cuenta con Modern Finance)
Phone number where I can be reached for confirmation ___________________________
(Numero de telefono para verificar)
Bank account holder’s name ________________________
(Nombre de la persona en la cuenta de banco)
Bank account holder’s signature _____________________________________________
(firma de la persona en la cuenta de banco)
Date
Signature #2 (if joint bank account) __________________________________________
(Segunda firma si hay dos personas en la cuenta de banco)
Date
First date I want my checking account debited: ____________________________
Date must be within 10 days of current due date and must be the 1st, 10th or 20th of the month
(Escoja el dia del debito, debe ser el 1, 10, o 20 del mes.)
(Esta fecha debe de ser durante los 10 dias de gracia)