Form RD-3550-28A Authorization Agreement for Preauthorized Payments

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USDA
Form RD 3550-28A

FORM APPROVED
OMB NO. 0575-0184

AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS
U.S. Department of Agriculture
Rural Development
CLSS - Commercial Loan Servicing System
PAPER WORK 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 maybe 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
MODIFY
CHECK ONE BOX NEW ___
INDIVIDUAL/ORGANIZATION NAME: (PLEASE PRINT)

____ CANCELL_____

1.
STREET ADDRESS:

CUSTOMER TELEPHONE NO.

2.
CITY/STATE:

3.
ZIP CODE:

4.
CUSTOMER REFERENCE NO. :
6.
PAYMENT CYCLE:

5.
RESERVED:

RULSS ACCT NO:

8.

7.
START DATE:

PAYMENT TYPE:

9.
PAYMENT AMOUNT:

12.
11.
SERVICING OFFICE TELEPHONE SERVICING OFFICE EMAIL ADDRESS:
NO.:
14.
13.
15.
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.

10.
SERVICING OFFICE CODE:

SIGNATURE: 16.

DATE: 17.

FINANCIAL INSTITUTION INFORMATION
FINANCIAL INSTITUTION NAME:
18.
STREET ADDRESS:
19.
CITY/STATE:

ZIP CODE:

20.
NINE-DIGIT ROUTING TRANSIT NUMBER:
22.
ACCOUNT TITLE:
23.
ACCOUNT NUMBER:

21.

25.

CHECKING
SAVINGS

24.
BANK REPRESENTATIVE SIGNATURE & TITLE

AREA CODE: BANK TELEPHONE #:

DATE:

26.

27.

29.

28.

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
collection of information.

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