AUTHORIZATION AGREEMENT FOR DIRECT DEPOSITS (ACH CREDITS)
Company Name: __________________________________________
Company ID Number: ______________________________________
I (we) hereby authorize _______________________________________________, hereinafter called COMPANY, to initiate credit entries to my (our) [ ] Checking [ ] Savings account (select one) indicated below at the depository named below, hereinafter called DEPOSITORY, to credit the same to such account.
DEPOSITORY
NAME: _________________________________________ BRANCH: ___________________
CITY: __________________________________ STATE: ___________ ZIP: _____________
ROUTING NUMBER: ________________________ ACCOUNT NUMBER: _______________
This authorization is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.
NAME(S): __________________________________ ID NUMBER: _____________________
DATE: ________________________
SIGNED: X___________________________________
SIGNED: X___________________________________
Please attach a voided check or deposit slip from the account you wish the credit deposited to insure correct information.