Account Debit Request Form
DATE: _________________
APPLICANT: ________________________________________________________________________
PROPERTY ADDRESS:________________________________________________________________________
________________________________________________________________________
I authorize AMC-America’s Mortgage Company to charge/debit my account the following amount:
$360 ( ) CONVENTIONAL $360 ( ) Suprime B,C,D
$385 ( ) FHA $385 ( ) VA Other: ______________
$200 ( ) Express Approval
Conventional FHA VA $__________________
(circle one)
TOTAL $__________________
( ) CHECK (fax a copy of a voided check with form)
( ) CREDIT CARD
Type: Mastercard Visa
American Express
Acct
#:___________________________________
Name: _______________________________ Expires _____________________
Address: _________________________________________________________
_________________________________________________________
( ) I Have enclosed a Check for the amount above
LOAN OFFICER:
______________________________________________________________
print
LOAN OFFICER:
______________________________________________________________
signature
____________________________________________________________________________________________________________
NOTICE