Electronic Funds/ach Authorization Form printable pdf download

Account Number______________________________________________________

Rep ID__________________ Alternate Branch _____________________

/ A c H A

l E c t r o n i c

u n d s

u t H o r i z At i o n

o r m

Workflow Case ID ______________________________

(

R B c c

)

c c o u n t

i t l e

A s s h o w n o n

o R R e s p o n d e n t

e R v i c e s c l i e n t s tAt e m e n t

A n k

c c o u n t

n f o R m At i o n

Required: Attach copy of voided check or bank document with ABA/routing and account number. (Deposit ticket is not acceptable.)

Set up new ACH service.

Replace existing ACH bank account number ____________________ with bank account information below. (List bank account number to

be replaced.)

Routing Number

Bank Name

Account Name

Account Number

Account Type

Checking

Savings

Dividends/Interest – Check here to receive your dividend and interest

payments via ACH. (Do not use for retirement accounts.)

A c h t

—

e c u R R i n g

R A n s A c t i o n s

d o n o t u s e f o R R e t i R e m e n t d i s t R i B u t i o n s

Modify existing recurring transaction of $ __________ effective on ____/____/____ with new recurring ACH transaction below.

Amount $

Add new recurring ACH transaction.

Incoming*

Outgoing

*Not permitted from third party accounts

Start Date

End Date

Weekly

Monthly

Quarterly

Semiannual

Annual

i g n At u R e s

RBC Correspondent Services, a division of RBC Capital Markets, LLC (“RBC CM”), Member NYSE/FINRA/SIPC, is authorized to initiate credit or

debit entries to the bank account identified above. The bank identified in this authorization will accept such credit or debit entries to the specified account,

without responsibility for the corrections thereof or the existence of any subsequent authorization relating thereto. This new deposit/transfer will start at the

time RBC CM is able to set up the account for ACH (which may take up to thirty (30) days) or on the given start date (whichever is later) and will remain

in effect until the given end date or another date selected by the client. The authorization may be changed or canceled by giving RBC CM notice fifteen

(15) days in advance of the effective date of such change or cancellation.

•

I understand that my use of ACH Services is subject to the terms and conditions of the Customer Authorization and Agreement for Electronic Funds

Transfers/Automated Clearing House Services contained in my client account agreement or in a separate document (the “ACH Agreement”), and

have received and reviewed a copy of the ACH Agreement.

•

If the RBC CM account is a trust, UTMA/UGMA, guardianship, conservatorship or other account created for the benefit of a third party, I represent

that all transactions effected hereunder are and will be for the benefit of the beneficiary of the RBC CM account as required by applicable law.

•

If I have selected incoming transactions from the bank account listed above, I certify that I am authorized to direct transfers out of such account and

by signing below I hereby consent to such withdrawals in my capacity as an authorized party on the bank account.

•

Authorized persons are permitted to transfer, deposit or pay money, and create, amend or terminate periodic transactions from or to this bank

account in varying amounts on the basis of verbal instruction, including instruction provided solely over the telephone.

The ACH Agreement has not been amended, altered or revised in any way by me, and I agree to be bound by, and to comply with, its terms and conditions

in their entirety.

Authorized Client Signature

Date

Authorized Client Signature

Date

Print Name from Signature Above

o R R e s p o n d e n t

i R m

t t e s tAt i o n

The undersigned Firm Authorized Signer hereby represents and warrants that the signature(s) of the person(s) signing on this form on behalf of the account

is/are genuine and that such signer(s) is/are an authorized party with the capacity and authority to bind the account, and agrees that the Firm will indemnify

RBC CM for any action taken in reliance on the above representations and warranties.

Firm Authorized Signer Signature

Date

Firm Authorized Signer Name (please print)

If transaction falls on a weekend or bank holiday, it will be processed the prior business day.

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RBC Correspondent Services, a division of RBC Capital Markets, LLC, Member NYSE/FINRA/SIPC.

R_UACHi (06/14)