Electronic Funds Transfer Authorization Form

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ELECTRONIC FUNDS TRANSFER AUTHORIZATION FORM
As a duly authorized check signer on the financial institution account identified below, I
authorize to perform monthly electronic funds transfer debits from the account identified below
for payments due or when applicable. This also applies to payments that I authorize by phone.
The amount of the monthly electronic funds transfers shall equal the amount as is detailed in the
applicable Secured Promissory Note and Agreement (the “Note”) or Equipment Lease (the
“Lease”) wherein is the named Maker or Lessee and this amount shall not change unless a
written amendment to the Note or Lease is properly signed by all applicable parties or
miscellaneous charges as detailed in the Note or Lease are imposed.
Authorizing Signature:
/
/201
Date
Attach
blank
VOID
Check
here
AND
Financial institution:
Branch:
Confirm
Check
City:
State:
ZIP CODE:
information
9 Digit Transit/ABA #
Account Name
Account #
101912

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