Anda di halaman 1dari 2

KwikPay Authorization Form

Yesenia . Gonzalez Name: ________________________________________ E805554888 Account number*: ________________________________

2753 N Whipple St Fl 1 Address: _______________________________________ IL 60647-1727 *If you do not have your account number, please provide your City, State ZIP: Chicago __________________________________
Phone number: __________________________________ Alternate phone number: ___________________________ Social Security Number: ____________________________ E-mail address: __________________________________

I authorize Nelnet to charge my checking/savings account to cover all my monthly student loan payments on my Nelnet-serviced loans. I agree that any payments not honored are my responsibility. Nelnet will not incur any liability or expenses as a result of these actions. I understand that sufficient funds must be in my account for payment. If sufficient funds are not in my account, I may be charged up to a $25 insufficient funds fee. Two occurrences of insufficient funds within 12 months may result in additional fees and/or the termination of my KwikPay agreement. I also understand that it is my responsibility to notify Nelnet of any changes regarding this account. I understand that to cancel or change KwikPay payments, Nelnet must receive notification from me at least ten (10) business days prior to the payments due date to allow adequate time for processing, though I may provide notification to Nelnet as early as three (3) business days before the due date. I can change or cancel KwikPay online at, via written notification to the fax number or address provided below, or over the phone with an advisor. I further agree to allow Nelnet to grant me a forbearance for all payments due (and not paid) before the begin date of my KwikPay payments. If my account(s) is placed in forbearance, all unpaid interest will be capitalized. This may result in an increase in my monthly payment. My monthly statement will reflect any change to my payment amount. This authorization shall be governed by and construed within the laws of the state of Colorado and the federal laws of the United States. I expressly authorize Nelnet and its representatives and related companies to contact me about my account at any phone number associated with me, including cellular and wireless phones, and to contact me using automatic dialing systems, artificial or prerecorded messages, text messages, or e-mail. Override Options: KwikPay Override Option: I authorize Nelnet to debit my monthly payment amount on behalf of my lender(s) from my checking/savings account regardless of the status of my loan(s). I understand that my account will be debited each month, even if my loan(s) is paid ahead or is in deferment or forbearance status. KwikPay Alternate ACH Amount Option: I authorize Nelnet to debit the amount below, which is greater than my monthly payment amount, from my checking/savings account each month to satisfy my monthly payment. I understand that the KwikPay Override Option will be placed on my Nelnet-serviced account. As a result my bank account will be debited each month, even if my loan(s) is paid ahead or is in deferment or forbearance status. Total monthly payment amount to be debited $_________________. Bank Information: Please complete the following. You may also submit a copy of a voided check or deposit slip from the bank account you wish to use. Checking account Savings account

Name of financial institution: ________________________________________________________________________ Address: _______________________________________________________________________________________ City: __________________________ State: _________________________ ZIP: __________________________

000000729516187 Bank account number: _____________________________________________________________________________ 071000013 Transit routing/ABA number: ________________________________________________________________________
I certify that I am the holder of the bank account. _____________________________________________________________ Borrower signature __________________ Date

P.O. Box 82561 | Lincoln, NE 68501 | p 1.888.486.4722 | f 1.877.402.5816 |

Please return the completed form to: Nelnet Attn: KwikPay P.O. Box 82526 Lincoln, NE 68501-2526 Fax: 402.323.4627 Simple. Safe. Smart. Visit and click Manage My Account to access your statements and account correspondence, sign up for automatic payments through KwikPay, make a payment, change your repayment option, apply for a deferment or forbearance, and much more! If you need additional information, please visit our website at or call us toll-free at 1.888.486.4722. Were here to help you reach your goals. Sincerely, Nelnet

P.O. Box 82561 | Lincoln, NE 68501 | p 1.888.486.4722 | f 1.877.402.5816 |