SAMPLE - Capital Bank
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ACH Origination Application
ACH Origination services will not be considered until the ACH Origination Agreement and ACH Origination Application are COMPLETED in their ENTIRETY.
Company Name: _______________________________
Date of Application: ___________ Telephone: ____________
Number of Years in Operation: _
Dollar Value of Transactions (per month):
Debits: _________ Credits: __________
Type of ACH Transactions (explain in detail):
WIRE TRANSFEERS
Further Indicate Below:
ARC - Accounts Receivable Truncated Check Debit RCK - Re-presented Check Entry
CCD - Cash Concentration or Disbursement POP - Point-Of-Purchase
ACK -Acknowledgement Entries PPD - Prearranged Payment and Deposit
COR - Automated Notification of Change or Refused Notification of Change
Capital Bank presently does not authorize its Originators to originate the following types of ACH –
TEL - Telephone-Initiated Entry
WEB - Internet-Initiated Entry
Other Accounts with Capital Bank (checking, savings, CD, loans):
|Account Type |Account Number |
| | |
| | |
| | |
| | |
Credit References:
|Name |Contact |Phone |Type of Business |
| | | | |
| | | | |
| | | | |
| | | | |
The undersigned hereby certifies that the information given in the foregoing statement is true and complete and is submitted for the purpose of obtaining ACH origination services. You are hereby authorized to obtain such information as you may require concerning foregoing statements which shall at all times remain the property of Capital Bank.
Signature of authorized representative of the Company:
Print Name: Title:
Signature:
Required Financial Information:
As stated in our ACH Origination Policy, Capital Bank will consider only ACH origination applications supported by a full financial disclosure. Three fiscal financial statements and an interim financial statement (after 90 days from the fiscal closing), including a balance sheet, profit and loss statement, and a reconciliation of surplus, are required. In addition, forecasts, aged accounts receivables and payable lists, appraisals of real estate or machinery and equipment, etc., may be required. No application will be considered unless required information is submitted.
ACH FUND TRANSFER AUTHORIZATIONS
The following information is required for every fund transfer template. Templates can be created for routine types of transactions. Photocopy and fill out this worksheet for as many templates needed.
1. ACH Template Name:
Transfer Type: ACH Out
Default Amount: $
From Institution R/T Number To Institution R/T Number: _
Account Name _ Account Name _ _
From Account: _ To Account: _ _
2. ACH Template Name: _
Transfer Type: ACH Out
Default Amount: $
From Institution R/T Number To Institution R/T Number: _
Account Name _ Account Name _ _
From Account: _ To Account: _ _
3. ACH Template Name: _ _
Transfer Type: ACH Out
Default Amount: $
From Institution R/T Number To Institution R/T Number: _
Account Name _ Account Name _ _
From Account: _ To Account: _ _
_______________________________________
Authorized Signature Name
___/___/___
Title Date
................
................
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