AUTHORIZATION AGREEMENT FOR ACH DEBITS
Customer Name:
Address:
City: State: Zip:
I, the Customer, hereby authorize the above named company to initiate debit entries and / or correction entries to my: Checking Account Savings Account
at the depository named below, to credit the same such account. The Customer acknowledges that the origination of the ACH transaction to the account must comply with the provisions of U.S. law.
Depository Name: Branch:
City: State:
Routing #  Click here for help on these numbers
Account #  
This authorization is to remain in full force until the above named company has received written notification from the customer of it's termination in such time and in such manner as to afford the company and depository reasonable time to act upon it.
Customer Name:    
*Customer Signature: *Date:
       
   
 
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