AUTHORIZATION AND AGREEMENT FOR AUTOMATED CLEARING HOUSE (ACH) DEBITS AND CREDIT
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.
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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