Ach Authorization Agreement For Citizen Working Abroad On Voluntary Contributions Form - Fsm Social Security Administration

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ACH Authorization Agreement
Direct Payments
AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (ACH DEBITS)
Company: FSM Social Security Administration
Company ID Number:
I / We hereby authorize FSM Social Security Administration, hereinafter called COMPANY, to initiate
Debit Entries to my/our
Checking Account
Savings Account (select one) indicated below at
the depository financial institution named below, hereinafter called DEPOSITORY, and to debit the same
to such account. I / We acknowledge that the origination of ACH transactions to my /our account must
comply with the provisions of U.S. law.
Depository (Name of Your Bank)
Bank Name/ Branch:_________________________________________________________________
Street / P.O. Box ______________City: ________________State: ________Zip:________
Routing Number: _______________________ Account Number: _______________________
This authorization 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.
th
The debit to my / our
Checking Account
Saving Account (select one) will be on the 10
day
following the end of every calendar quarter beginning, (Check one)
3/31
6/30
9/30
12/31
AMOUNT $ 175.00
AMOUNT IN WORDS: One Hundred Seventy Five Dollars & 00/100 Only
Name(s): ________________________________________ SS Number:___________________
(Please print)
Mailing Address__________________________________________ Zip Code ______________
Telephone Number(s): Home: ______________________ Work: _________________________
Employer ____________________________ Address __________________________________
State Citizenship:
Chuuk
Pohnpei
Kosrae
Yap
Signature:_______________________________________________Date:______________________
Note: All written debit authorizations MUST provide that the receiver may revoke the authorization only
by notifying the Originator in the manner specified in the authorization.
Please return to:
Call: (691)320-2708/2707/2706
FSM Social Security Administration
Fax: (691)320-2607
P.O. Box L
E-Mail:
fsmssa@mail.fm
Kolonia, Pohnpei
Website:
FM 96941

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