REGIONS BANK D/B/A REGIONS MORTGAGE AUTOMATIC

REGIONS BANK D/B/A REGIONS MORTGAGE

AUTOMATIC PAYMENT AUTHORIZATION

If you would like us to automatically debit or draft a deposit account for your loan payment each month, please mail form with the Required

Documents to: Regions Mortgage-Customer Service, Draft Specialist

P.O. Box 18001

Hattiesburg, MS 39404-8001

Or, you may fax the completed form and Required Documents to: ATTN: Draft Specialist at (601) 554-2385,

Or, sign up online at regionsmortgage.com, select the “payments” tab, and follow the instructions.

You must continue to make your monthly loan payments by other means until the automatic debits begin. You will be notified in writing of the

date when automatic debits will begin.

AUTOMATIC PAYMENT AUTHORIZATION APPLICATION

Loan Number:

Mortgagor(s) Name(s):

Name(s) on Deposit Account (Signature card required on business accounts):

Phone Number: Home

Work

Name of Your Depository Bank:

Banks ABA or Routing Number (must be 9 digits):

Checking/Savings Account Number:

CHECKING (ATTACH VOID CHECK) SAVINGS

Select the date your payment will be drafted (between 1st and 15th of month):

Select the month you prefer the automatic debits to begin:

ADDITIONAL PRINCIPAL (OPTIONAL)

I wish to have $__________________________ drafted, and applied to PRINCIPAL ONLY. I understand this is an extra amount IN

ADDITION to my payment in the amount of $______________________________.

AUTOMATIC MORTGAGE PAYMENT PLAN AGREEMENT: By signing below, I authorize Regions Bank to debit the Deposit account,

identified above, for monthly payments due on the loan identified above and any additional amount indicated above. I understand that the

amount debited monthly will include any changes in the monthly payment resulting from changes in my escrow items and/or changes under my

loan documents and/or changes required by law. Automatic debits scheduled on a weekend or holiday will be made on the next business day. If

the loan becomes delinquent, the automatic debit may be discontinued. If the automatic debit is discontinued, the mortgage payments must be

made by other means. I will be notified if the automatic debit is discontinued. I will be responsible for any late charges or penalties.

I am responsible for making the payments due on the loan by other means if my payment is not debited by the date specified,

no matter why the debit does not occur.

Signature Date Signature Date

You may revoke this authorization at any time by sending a written request to: Regions Mortgage,

Attn: Draft Department,

P.O. Box 18001,

Hattiesburg, MS 39404-8001.

Or, you may fax the revoking request to 601-554-2385. To prevent further debiting the next scheduled payment, we must receive this request at least

nine daysin advance of a scheduled debit.