Payment Authorization

I authorize Home Loan State Bank (Lender) to automatically withdraw the payment amount from my personal account within 5 days of this authorization date.  If the funds in the account are insufficient to cover any payment, Home Loan State Bank shall assess disclosed fees and/or penalties.

I understand that I must continue to remit my monthly payment by check and this authorization is for the dated payment discussed with the bank official.

I understand that this is a one time authorization for payment and by clicking the submit button, I am authorizing Home Loan State Bank to debit my personal account and apply it to my loan payment.

  I agree with the above terms*
    e-Mail Address*
    Date* (mm/dd/yy)