AUTO DEBIT AUTHORIZATION
By using Auto Debit offered through Citizens Bank, N.A. (“Citizens”), your monthly payment will be automatically deducted from an account you designate on the payment due date specified in your
motor vehicle sales contract, loan note or line of credit agreement.
Please make sure to fill out all fields below and read the form carefully. If this form is not completed or is filled out incorrectly, it will be returned to the customer.
Once we have processed your request, it may take up to two statement cycles for automatic payments to take effect. Please continue to make any payments that are due in the interim, as you normally
would, until you see the Auto Debit appear on your debiting account statement.
When you request Auto Debit for your account, please note that your account must not be past due.
If you make additional payments toward your account, the amounts may advance your monthly payment due date, thereby interrupting your Auto Debit schedule; to avoid this, please specify on your
payment coupon or other payment method that the payment should be applied to “principal only.”
If, for any reason, Citizens is unable to deduct payments from your account, you will still be required to remit your monthly payment amount. We may choose to terminate this agreement, with
notice, if a transaction fails.
If your payment is returned unpaid, you authorize us to make a one-time electronic fund transfer from your account to collect a fee. The fee will be determined by the contract, note or applicable law. Your
final payment will not be drafted by Auto Debit. Instead, you will receive a statement with the amount that you will be required to pay in order to close the account.
CUSTOMER INFORMATION
FINANCIAL INSTITUTION INFORMATION
LOAN ACCOUNT NO.
FINANCIAL INSTITUTION NAME
CUSTOMER NAME
ADDRESS
STREET ADDRESS
NAME(S) ON WITHDRAWING ACCOUNT
CITY
FINANCIAL INSTITUTION (debiting checking or savings) ACCT. NO.
STATE, ZIP
FINANCIAL INSTITUTION ROUTING NO. (9 DIGITS)
Auto Debit is not accepted for amounts less than minimum monthly payment due under the contract ACCOUNT TYPE:
and only one auto debit is permitted per month.
Checking Account
Savings Account


Verify with your financial institution that your savings account may be used for Auto Debit
CDs and credit cards cannot be used with this feature.
By signing below, I authorize Citizens and its successors and assignees to automatically deduct from my checking or savings account indicated above the amount of my monthly payment, until (1) all
payments required by the contract except final payment have been made or (2) Citizens has received notification from me to terminate the Auto Debit plan, according to the instructions and
pursuant to the conditions listed above.
ACCOUNT HOLDER’S SIGNATURE:
X
DATE
JOINT ACCOUNT SIGNATURE (if applicable)
X
BANK COPY
DATE
Important Auto Debit Disclosure Information
Cancellations: To cancel or stop payment of a preauthorized EFT/ACH transaction, you must notify us three or more business days before
the scheduled transfer. If notice is provided less than three days before the scheduled transfer, the EFT/ACH transaction may be paid.
Confidentiality: We will only disclose information to third parties about your account or the transfers you make: 1) when it is necessary to
complete transfers; 2) to verify the existence and condition of your account for a third party, such as a credit bureau or merchant; 3) to
comply with government agency or court orders; or 4) if you give us written permission.
Additional Principal Payments: If you wish to make additional principal payments to your loan, mail the principal payment to the address
on your statement. Please include the payment ticket that is at the bottom of the statement and write the amount on the principal line of
that ticket. If the ticket is not filled in correctly, the payment could be applied as a regular payment and may advance your due date.

If you reside in RI, MA, NH, CT, VT, NY, PA, MI, OH, or DE, you may also make a principal
payment at one of our branch locations.

If you have deposit accounts with Citizens Bank, you can easily make principal payments through online
banking at citizensbank.com.
Contact Us: If you have any questions, please contact us at 800-708-6680; we’re available 24 hours a day, seven days per week.
Or fax to 877-362-6343 Attn: Auto Debit Support Team
Or you may write us at:
Citizens Bank
Consumer Loan Servicing
ROP 10K
P.O. Box 42002
Providence, RI 02940-2002
CON-CO-LS-AUDB-020-DEC15