ACH Authorization Form - List Yourself



|ACH Authorization Form | |

|Please type all information requested directly into the form below by tabbing to each field and replacing its contents with your own information. Then, | |

|print it, sign it, and fax it to 1-413-480-3977. Or email it to help@ | |

| | | |

|Your Personal or Company Name | |

|as it appears on your check: | |

|Your Personal or Company Street | |

|Address as it appears on your check: | |

|Your Personal or Company City, | |

|State, and Zip Code as they appear on your check: | |

|Bank Name as it appears on your check: | |

|[pic] | |

|The nine (9) digit Bank Routing Number: |[pic][pic] |

| | |

|Account Number: |[pic][pic] |

|Retype Account Number: |[pic][pic] |

|Please write "VOID" on the top of the actual check, copy it, and fax it along with this form. |

|Please type your mother's maiden name for security purposes: | |

|Print Name (and title if a business) of the authorized signer on account: | |

|Telephone Number of Authorized Signer: | |

|Debit Amount: | |

|Type YES to authorize ACH DEBIT for Deposits and Other Payments: |

|I hereby authorize , Inc., upon receipt of a facsimile or authenticated e-mail from me, to initiate and process a debit transaction through |

|JPMorgan/Chase Bank and the Automated Clearing House, for payment of deposits and other charges to my account. |

|This authorization is to remain in full force and effect until , Inc. has received written notification of change. |

|Attach a voided check to verify the bank account information listed above. |

|Type YES to authorize ACH CREDIT for Refunds and Other Credits: |

|I hereby authorize , Inc., to initiate and process credit transactions through JPMorgan/Chase Bank and the Automated Clearing House, for |

|payment of refunds or other credits to my account. |

|This authorization is to remain in full force and effect until , Inc. has received written notification of change. |

|, Inc. may initiate an ACH Pre-Note through my financial institution at any time prior to commencement of services. |

Bottom of Form

Authorized Signature: ______________________________________________________________

Date (MM-DD-YYYY): ______________________________________________________________

PRINT, SIGN, AND FAX THIS FORM TO: , Inc. 1-413-480-3977 (fax).

If this form is for a business checking account, we must receive it no later than

7:00pm Central Time, two (2) business days prior to deadline.

If this form is for an individual's checking or savings account, we must receive it no later than

7:00pm Central Time, three (3) business days prior to deadline.

Questions? Call 1-914-217-4475.

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