As a duly authorized check signer on the financial institution account identified below, I (we) authorize (COMPANY) to perform scheduled or periodic electronic funds transfer debits and / or credits from my account identified below for payments due or when applicable, apply electronic funds transfer credits to the same. 

Furthermore, if any such electronic debit(s) should be returned by my (our) financial institution as Non-Sufficient Funds (NSF), I (we) authorize (Company) to collect a returned item fee of $30.00 per item by electronic debit from my (our) account identified below.  For accounting purposes, all electronic debits will be reflected in the monthly bank statement that corresponds with the financial institution account identified below. 

I understand and authorize all of the above as evidenced by my (our) signature below.


Company Name                               Signature                                               Date

Financial Institution account “identifying information”: 

Financial Institution Name(Bank Name):  Bank Service Representative:
Bank Street Address:  City/State/Zip:
Bank Phone Number:  Bank Fax Number:
ACH Routing / Transit / ABA Number (9 digits)  Account Number:
Financial Institution 00001    Date: _____________________  Pay to the order of ___________________________________ $   Memo ________________________      This is the 9 digit Transit/ABA Bank Routing number 🡪 XXXXXXXXX 0000000000 🡨 The account number is usually to the  ie. right of the Routing number. Some  Financial Institutions add the check  number between the Routing and    Account number. 

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