Mortgage Automatic Payment Form

Request Type

Mortgage Loan Number

Name

Co-Borrower's Name

Email

Mailing Address

City

State

Zip Code

I hereby authorize Johnson Bank to transfer the initial payment sum of

and additional principal

and additional escrow

Starting on this day (1st thru the 10th ONLY)

and continuing on the same day each month thereafter until written Notice of Cancellation is provided per the terms stated.

Account To Transfer Money From Johnson Bank Other Institution

Account Type Checking Savings

Account Number

Routing Number

Name of Other Institution

City

State

Authorize

I understand that by clicking submit, I hereby authorize Johnson Bank to process an automatic monthly transfer on my behalf from my deposit account at the financial institution named previously. I hereby authorize the amount to be transferred each month shall be the amount of the monthly mortgage payment at the time of the transfer. I further authorize changes in the amount of the monthly transfer as required under the terms of the note and mortgage. Either I/(we) or Johnson Bank may cancel the Automatic Payment Option contemplated by this agreement upon written notice 5 business days prior to the 1st of the month.