Instructions - Please complete all 4 steps. If you would like to authorize Heartland ECSI to deduct your monthly payments by automatic deduction please: 1. Complete the form below. If your account is a joint account both account holders must sign this form. 2. Attach a voided, unsigned check to the form. 3. Return the original form and the voided check to Heartland ECSI. 4. Retain a copy of this form for your files. We will process your account for automatic deduction as soon as possible after we receive your form. The authorization form must reach our office by the 10th of the current month to begin your automatic payment for the following month. Therefore, if you receive any additional student loan bills after sending in this form, please call our office before making the payment shown on that bill. ACH Authorization Form I (we) hereby authorize Heartland ECSI to initiate debit entries to my (our) account in the entity named below (“institution”), and I (we) authorize the institution to accept and to debit the amount of such entries to my (our) account. Each debit shall be made each month in an amount equal to the withdrawal amount indicated.                    Checking             Savings            (Check One)             Bank (Institution) Name      Or              Credit Union     (Check One) Address City State Zip Transit/ABA No. (First nine digits encoded on your check) $            . Account Number Withdrawal Amount Withdrawal Date: 1st 10th 15th 20th Start Date: mm/yy This authorization is to remain in full force and effect until all amounts payable to the school, for my student loan(s) are paid in full or until I revoke the agreement as hereinafter provided. Any revocation shall not be effective until Heartland ECSI has received written notification from me of my desire to terminate this agreement in such time and in such manner as to give Heartland ECSI a reasonable opportunity to act on it. I understand that I will be notified of any payment changes debited to my account. Heartland ECSI reserves the right to cancel a borrower’s participation at any time. Borrower’s Name Social Security Number Account Holder’s Name (please print) Holder’s Signature (Joint Accounts) Holder’s Name (please print) Second Holder’s Signature Date of Authorization Account Holder’s Telephone Number E-mail: Check here          for e-bill Please Return To:   Heartland ECSI P.O. Box 1278 Wexford, PA 15090