Direct Payment Authorization Form




























Account Type

You have the option to split your payment into
two different withdraw dates.
Do you want to split your payments?
Payment date.
Payment start date.
Payment start date.
Payment start date.
Payment dates.
Payment start date.
Payment start date.



















Phone Type





*By selecting "Moblie", I authorize UHEAA to contact me regarding my request or my loan(s), including repayment of my loan(s), at the number that I provide on this form or any future number that I provide for my cellular telephone or other wireless device using automated telephone dialing equipment or artificial or prerecorded voice or text messages.