HTML Preview Work Authorization page number 1.
MGIC
Authorization for Electronic Receipt of Payment (ACH)
Lender Name:
Address:
City, State, ZIP Code:
I, _____________________________________________, the _____________________________________ of
___________________________________________ ("Lender") authorize Mortgage Guaranty Insurance
Corporation and its affiliates (together, "MGIC") and the Financial Institution listed below to initiate deposits of
funds electronically to the account identified below (the "Account"), for amounts payable by MGIC to Lender.
Such deposit shall be in lieu of payment by check. If funds to which Lender is not entitled are deposited to the
Account, MGIC will so notify Lender and Lender will initiate a payment to return said funds to MGIC. This
authorization will remain in effect until Lender has cancelled it by written/fax notice, and only upon receipt of
such written notice by MGIC at the fax number below, in which case it will be effective on a date determined
by MGIC, which is no later than ten business days after MGIC's receipt.
Financial Institution Name:
Financial Institution Address:
City: State:
ABA Routing Number:
Account Number to be Credited:
Account Type: Checking Savings General Ledger
Authorization Signature: Title:
Date: Phone:
E-mail:
Please direct any questions to MGIC Cash Management Department, 1-800-558-9900 X6611 or X2659.
Fax form to: MGIC Cash Management, 414-347-6354
Cash Management Use Only
PreNote Date: _____/_____/_____
Vendor Number: C
Form #71-20851 (12/10)