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Get USDA RD 3550-28 2005

USDA Form RD 3550-28 05-05 FORM APPROVED OMB NO. 0575-0184 AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS U.S. Department of Agriculture Rural Development PAPERWORK REDUCTION ACT AND PRIVACY ACT STATEMENT The following information is provided to comply with the Privacy Act of 1974 P. L* 93-579. The information requested on the form is required under various provisions of title 15 U*S*C. 1601 12 CFR 205 and 31 CFR 202 for the purpose of providing authority to the Department of Treasury to designate financial institutions to collect payments by electronic means from your account. The information will be used for identification with the records of the government agency and the financial institution to direct your payments to the point you authorize. No deduction may be made unless a signed authorization form is received* Failure to furnish this information may delay or prevent the collection of these payments through the Automated Clearing House System* INDIVIDUAL/COMPANY INFORMATION INDIVIDUAL/ORGANIZATION NAME PLEASE PRINT STREET ADDRESS BORROWER TELEPHONE NO. CITY/STATE ZIP CODE BORROWER CASE NO. PAYMENT INTERVAL PROJ* NO. AMAS FC/LN START DATE LOAN TYPE PAYMENT AMOUNT SERVICING OFFICE CODE NO. I hereby authorize the initiation of a deduction from the account and the financial institution named below to debit such account. I understand I will be notified if the debit amount needs to be adjusted either to be increased or decreased* I also understand that I have the right to stop automatic payment by notifying my financial institution in writing three days prior to the time my account is charged* SIGNATURE DATE 17. FINANCIAL INSTITUTION INFORMATION NINE-DIGIT ROUTING TRANSIT NUMBER ACCOUNT TITLE ACCOUNT NUMBER CHECKING BANK REPRESENTATIVE SIGNATURE TITLE AREA CODE SAVINGS BANK TELEPHONE DATE According to the Paperwork Reduction Act of 1995 an agency may not conduct or sponsor and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0575-0184. The time required to complete this information collection is estimated to average 30 minutes per response including the time for reviewing instructions searching existing data sources gathering and maintaining the data needed and completing and reviewing the. L* 93-579. The information requested on the form is required under various provisions of title 15 U*S*C. 1601 12 CFR 205 and 31 CFR 202 for the purpose of providing authority to the Department of Treasury to designate financial institutions to collect payments by electronic means from your account. 1601 12 CFR 205 and 31 CFR 202 for the purpose of providing authority to the Department of Treasury to designate financial institutions to collect payments by electronic means from your account. The information will be used for identification with the records of the government agency and the financial institution to direct your payments to the point you authorize. .

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