Direct Deposit (Ach Credit) Authorization Form printable pdf download

Internal Use Only: EGID:_____

New Application

Revised/Updated Application

VN/FN: __________________

Account #: __________________

Direct Deposit (ACH Credit) Authorization Form*

Organization:__________________________________ Federal ID #: ___________________

Telephone: ____________________ Website:_______________________________________

Physical Address:_________________________________________ Zip Code: ____________

The Organization hereby authorizes E-Giving (“Company”), the financial institution listed

below, and Company’s financial institution, to initiate electronic entries, and if necessary,

process any adjustments needed to correct entries made in error, to the following account. The

Organization acknowledges that its origination of ACH transactions through Company to its

account must comply with all applicable laws and regulations, and underwriting limits may be

applied to transactions in the sole discretion of Company, Company’s financial institution, and

Organization’s financial institution listed below. This authority will remain in full force and

effect until Company receives a written notice to cancel, with a reasonable opportunity for

Company and the financial institutions to effect the cancellation.

Financial Institution Name: __________________________________________________

9-Digit Routing #: __________________________ Account #: __________________________

Checking Account

Savings Account

The financial institution listed is hereby authorized to release information requested by Company

for underwriting purposes.

The parties below certify that they are both fully authorized to a) execute agreements on behalf

of the organization; b) change the account information above; c) receive full access to

administrator features; and d) receive notice of significant information (such as a request to

change the Organization’s Account).

E-Giving Administrator

E-Giving Administrator (required)

___________________________________

_______________________________________

Signature – Authorized by

Signature

___________________________________

_______________________________________

Please Print Name

Please print Name

___________________________________

_______________________________________

Title

___________________________________

________________________________________

Date

___________________________________

________________________________________

Email Address

E-Mail Address

□

Send Login to this E-Mail

(choose one only)

Send Login to this E-Mail

(choose one only)

(1-888-219-5622)

Complete this form and FAX to: E-Giving

Direct Deposit (Ach Credit) Authorization Form

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