Debit Authorization Form printable pdf download

Debit Authorization Form

I (we) hereby authorize ___________________________________________, hereinafter called

COMPANY, to initiate debit entries to my (our) account indicated below and the financial

institution named below, hereinafter called FINANCIAL INSTITUTION, to debit the same such

account. I (we) acknowledge that the origination of ACH transactions to my (our) account

must comply with the provisions of U.S. law.

Please attach a voided check to this form. Citizens State Bank will not process this request

without a voided check.

(Financial Institution Name)

(Ph. Number)

(Address)

(City/State)

(Zip)

______________________________

___________

___

Checking ___Savings

(Routing Number)

(Account Number)

Amount of payment: $__________________ Start Date of ACH: _________________

Frequency of ACH: ____________________ End Date of ACH:__________________

This authority is to remain in full force and effect until COMPANY has received written

notification from me (or either of us) of its termination in such a time and manner as to afford

COMPANY and FINANCIAL INSTITUTION a reasonable opportunity to act on it.

____________________________________

_________________________

(

Print Individual Name)

(Date)

_______________________________________

(Signature)

Company Acct Information

____________________________________

____________________

(Citizens State Bank Customer Signature)

(Account Number)

Bank Use Only

Date Received:

Completed By:

Verified By:

Debit Authorization Form