Amscot -- Customer Revocation of Authorization for Automatic Debit(s)

Please stop taking automatic payment(s) from my bank account for payments to my Cash Advance or Installment Cash Advance. My account number with your company is included below. I am writing to inform you that I am revoking authorization for you to debit my account via electronic funds transfer (please select only one option below):

This revocation applies to any and all future debits for the current cash advance or current installment cash advance I have taken out.

This revocation applies only to the next scheduled payment. I have not revoked authorization for any other debits.

Please note that your payment continues to be due as scheduled. If you cannot pay on time, please call us to discuss payment arrangements at (813) 637-6280.

Customer Information

(Failure to provide complete information below may result in a delay and/or inability to complete your request.)

Name:

Date of Birth:

Telephone Number:

Transaction Date:

Last 4 digits of your Checking Account Number:

Is This Account Closed:

Yes

Amscot must receive this form before your check is sent to the bank on the due date. It may take up to three (3) days before your scheduled due date for Amscot to affect the revocation if you are making this request on a holiday or weekend. If we receive this form after such time, your revocation will not be effective until the following due date for your outstanding transaction, if one is applicable.

Submit this form online, send a written request by mail, or call us:

By Mail to:
PO BOX 25137
Tampa, FL 33622
You may also call us at (813) 637-6280 and we will do our best to assist you. Please have the above information ready if calling over the phone.