ACH TRANSACTIONS AUTHORIZATION AGREEMENT

NEW REVISE TERMINATE (Check One)
I (we) authorize [INSERT YOUR COMPANY NAME HERE] to electronically debit my (our) account
(and, if necessary, electronically credit my (our) account to correct erroneous debits) to my CHECKING
SAVINGS account (Check One) at the financial institution (Bank) named below.
Bank Name ______________________________________________________________________________
Bank Address ____________________________________________________________________________
Routing Number ____________________________ Account Number _______________________________
ATTATCH VOIDED CHECK HERE
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