Keystone Payroll Form Ad-2002 - Authorization Agreement For Automatic Deposit printable pdf download

Keystone Payroll Form Ad-2002 - Authorization Agreement For Automatic Deposit

KEYSTONE PAYROLL FORM AD-2002

AUTHORIZATION AGREEMENT FOR AUTOMATIC DEPOSIT (ACH CREDITS)

PLEASE PRINT CLEARLY

COMPANY NAME: _________________________________________________

ID#: ________________________

I (we) hereby authorize, hereinafter called COMPANY, to initiate credit entries and to initiate, if

necessary, debit entries and adjustments for any credit entries in error to my (our) account indicated

below and the depository named below, hereinafter called DEPOITORY, to credit and/or debit the same

to such account.

DEPOSITORY NAME: ________________________________________________________________________________

BRANCH: __________________________________________________________________________________________

CITY: ________________________________________________________

STATE: ________

ZIP: _____________

ACCOUNT 1

ACCOUNT 2

ACCOUNT # _____________________________________

TRANSIT/ABA#: __________________________________

TYPE:

CHECKING

SAVINGS

TYPE:

CHECKING

SAVINGS

AMOUNT: _______________________________________

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 time and in such manner as to afford COMPANY and

DEPOSITORY a reasonable opportunity to act on it.

NAME (S): ________________________________________________________

ID#: ________________________

(PLEASE PRINT)

NAME (S): ________________________________________________________

(PLEASE PRINT)

SIGNED X:: _______________________________________________________

DATE: ______________________

SIGNED X:: _______________________________________________________

Keystone Payroll Form Ad-2002 - Authorization Agreement For Automatic Deposit