EFT AUTHORIZATION FORM    

 I authorize LZL to withdrawal bi-weekly from my account one-half of my monthly mortgage payment shown below.

(Note: Additionally a $2.50 fee will be withdrawn with each electronic transfer.)

Customer / Bank Information

Customer Name:  

Home Address:                   

City, State, Zip Code:         

Telephone Number:                

Email Address:                    

Bank Name:          

Bank Route Code Number ( 9 digits):                  (Help)

Bank Account Number:                                         (Help)

(Please include a voided check)

 

Mortgage Information

 

Total Monthly Payment Due $

 

Day of the Month Payment Due:       (i.e. 1st, 15th)                Grace Period 

 

Mortgage Account Number:             

 

Mortgage Company’s Name:                            

                                Street Address:                   

                                City, State, Zip Code:         

                                Telephone Number:            

 

Start Date

I Authorize LZL to withdraw bi-weekly from my Account starting:  Month Year   (Help)

I prefer to begin my program on the  of the month and year I authorized above.  (Help)

 

Signature _____________________________________________ Date ____________________________

 

 

 

LZL Equity Programs Company <> PO Box 58136 <> Cincinnati, OH <> 45258

PHONE: 513-347-3293 <> FAX: 513-347-3644 <> EMAIL: lzl@fuse.net

Office Hours: Monday thru Friday 9:00 am – 3:00 pm EST