Ach Transaction Authorization Form printable pdf download

ACH TRANSACTION AUTHORIZATION FORM

I hereby authorize Greenway Cooperative to automatically debit my account designated below

for payment of balances or invoices for charges to my account as indicated below.

Name: ______________________________________

Greenway Account: __ __ __ __ __ __

Address: ______________________________________________________________________

City: _______________________________

State: _______ Zip: __ __ __ __ __

E-Mail Address: _________________________ Contact Phone #: ____________

BANK ACCOUNT INFORMATION (Or Attached Voided Check)

Bank Name: _____________________________________ City: _______________ State: ___

Account Number: _________________________________

Checking

Savings

Bank Routing Number: ________________________________ Bank Phone #: ___-___-______

ACH METHODS (Choose One)

Statement Amount (Balance owed at the End of the previous month to be ACH on the 25

of each current month.)

Invoices by Terms (An ACH transaction will be made as invoices are charged, normally

on a weekly basis, each Friday)

Budget Amount Due (If you are on an Even Payment Plan for Home Heat, the monthly

payments due will be ACH’d on the 25

of each month.)

One Time Payment (This choice gets your file set up but you must call to make

arrangements each time you wish to make a payment via ACH)

ACH NOTIFICATION INFORMATION

Notifications will be sent by E-Mail approximately 5 days prior to the actual ACH transaction. If

you do not have an e-mail address, no notification will be sent.

MONTHLY BILLING STATEMENTS (Go Green)

E-Mail the Monthly Billing Statements to above E-Mail Address

Authorized Signature: ___________________________________ Date: ___/___/______

Print Name: ____________________________________

RIGHTS AND CONDITIONS

1. You may cancel your ACH Authorization at any time by notifying Greenway in writing

10 days in advance of an ACH transaction. Upon its cancelation, all information relating

to the authorization will be deleted from the file.

2. ACH payments returned for insufficient funds or account closed will automatically

remove and cancel your ACH Authorization and may be charged insufficient fund fees in

accordance with our credit policy.

Please mail completed form to: Greenway Coop, P.O. Box 6878, Rochester MN 55903.

Ach Transaction Authorization Form