ATTENTION:  PAT MORGAN
UNIVERSITY OF UTAH INCOME ACCOUNTING & STUDENT LOAN SERVICES 201 SOUTH 1460 EAST, ROOM 165 TELEPHONE:  581-8786     FAX:  581-4277
AUTHORIZATION AGREEMENT FOR PREAUTHORIZED LOAN PAYMENTS
I hereby authorize the University of Utah's Income Accounting & Student Loan Services Department and the financial institution shown to initiate debit entries and, if necessary, credit the same to the financial institution and account listed below, for loan payments.  If there are insufficient funds in my bank account when it is debited, I understand I will be assessed fees similar to those charged for a dishonored check.  I understand that it is my responsibility to ensure funds are available and are correctly withdrawn each month.  The University will not be liable for bank charges resulting from problems associated with direct withdrawal.
This authorization is to remain in full force and effect until the University has received written notification from me (or either one of us) of its termination in such time and in such manner to afford the University and the University's depository bank a reasonable opportunity to act on it.
CHECK APPROPRIATE BOX:
NEW SET-UP*	CHANGE INFORMATION*	CANCEL DIRECT PAYMENT
INFORMATION AND AUTHORIZATION NAME (please print) DATE     BORROWER ACCOUNT NUMBER SIGNATURE (required)     LOAN TYPE PHONE NUMBER
FINANCIAL INSTITUTION BANK OR CREDIT UNION NAME ACCOUNT TYPE (check one)    Checking         Savings TRANSIT (ABA) NUMBER ACCOUNT NUMBER     START DATE AMOUNT
PLEASE ATTACH A VOIDED CHECK OR DEPOSIT SLIP
*Allow ten working days for required processing.
PRINT THIS FORM, COMPLETE, AND DELIVER TO THE ADDRESS LISTED ABOVE