3. Sign and Date
I (we) hereby authorize and request Lexus Financial Services (LFS) to initiate electronic debit entries or effect a charge by any other commercially accepted practice
to my (our) checking/savings account indicated at the financial institution identified in this authorization, and I (we) authorize and request said financial institution to honor
the debit entries initiated by LFS and debit such account. This authorization is for payments described in the related retail contract or lease agreement, or those payments
as they may be changed, from time to time, by LFS. This authority is to remain in effect until LFS and the financial institution listed have received written notification from
me (or either of us) of its revocation in such a manner and time as to afford LFS and the financial institution a reasonable opportunity to act upon it, all payments required
by the retail contract or lease agreement have been made or LFS cancels the debit as set forth below. I (we) understand and agree that LFS may cancel the electronic
debit on my (our) account at any time, including if an electronic debit is denied payment by my (our) financial institution. I (we) understand that I (we) will remain re-
sponsible for the payments due under the terms of my retail contract or lease agreement. I (we) acknowledge that the originator of electronic debit transactions to
my (our) account must comply with the provisions of United States law.
X _________________________________________________________ __________________________________________________________
Customer Signature Date Joint Signature (if applicable) Date
AutoCheque saves you time and postage, and best of all helps alleviate the worry of making payments on time. By utilizing AutoCheque, your
monthly payment will be debited from an account you designate. So, enroll now and make your payments electronically the easy way!
Step 1: Complete the customer information section.
Step 2: Complete the financial institution information section. List the name on the account, including any joint account holder.
Step 3: Sign and date the enrollment form.
Step 4: Write “VOID” across a check or savings deposit slip preprinted with your name, address and account number from the account you
designate and attach to the completed enrollment form. Information contained on the check/savings deposit slip is used by LFS and
your financial institution to complete the enrollment process.
Step 5: We have provided two copies of this form. One needs to be mailed to Lexus Financial Services, and one should be kept for your
records. Please keep a copy of the voided check or savings deposit slip for your records as well.
Step 6:
Place the completed enrollment form and the voided check or savings deposit slip into a properly addressed envelope and mail to:
Lexus Financial Services, P.O. Box 9490, Cedar Rapids, IA 52409
Allow a minimum of 14 days for your account to be converted to AutoCheque. Make any payments on your account, as required, until receipt of
notification that you are enrolled in AutoCheque. You may wish to verify that your financial institution offers this service for your specific account.
1. Customer Information
Customer Name: _________________________________
Address: _______________________________________
City: __________________________________________
State: _________________________________________
Zip: ___________________________________________
LFS Account Number (10 or 11 digits):
LFSwillprovideamonthlybillingstatement
foryourrecords.
2. Financial Institution Information
Financial Institution (check one): u Bank u Savings & Loan u Credit Union
Financial Institution Name: ____________________________________________________
Address: _________________________________________________________________
Name on Account: _________________________________________________________
Joint Name on Account (if applicable):
_______________________________________________________________________
Designated Account (check one): u Checking u Savings
Account Number (include voided check/savings deposit slip):
________________________________________________________________________
Financial Institution Routing Number (9 digits):
LFS Monthly Payment Amount†:
†
Monthly Payment Amount you designate must be the same as listed on your retail finance contract or lease
agreement.
.
$
MAIL THIS COPY TO LEXUS FINANCIAL SERVICES
AutoCheque
E L E C T R O N I C P AY M E N T P R O G R A M