Automated Clearing House Form - Ach Debit Authorization For Prepaid Funeral Contract Sellers - Texas Department Of Banking

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Texas Department of Banking
AUTHORIZATION FOR DIRECT PAYMENT OF REGULATORY ASSESSMENTS
(ACH DEBIT)
I hereby authorize the Texas Department of Banking (the “DOB”) and/or the Texas Comptroller
of Public Accounts, on behalf of the DOB, to initiate debit entries to the deposit account (the
“account”) indicated below at the depository financial institution (the “Depository”) indicated
below, and to debit the same to the account. I understand that debit entries will be initiated from
the account to pay annual renewal and assessment fees owed the DOB pursuant to Section
25.23 of the Texas Administrative Code and that I will be given at least a 15-day notice prior
to the debit entry. I acknowledge that the entries must comply with the provisions of U.S. law.
THIS FORM MUST BE SIGNED BY AN AUTHORIZED AGENT.
Depository Name ______________________________________________________________
Branch _______________________________________________________________________
City __________________________________________ State _______ Zip ______________
Bank Contact Name ____________________________________________________________
Bank Contact Phone Number _____________________________________________________
ACH/Routing Number (9 digit number) _____________________________________________
Account Number _______________________________________________________________
Type of Account (Check only one) ☐Checking
☐Savings
FEES CANNOT BE WITHDRAWN FROM YOUR PREPAID FUNERAL BENEFITS ACCOUNT.
This authorization will remain in effect unless terminated because of a corporate reorganization. The account information will
remain effective unless modified because of a change in the account to which debits are authorized. I understand that written
notice of a termination or modification must be provided to the DOB at least 30 days in advance of a scheduled debit.
Name of Permit Holder __________________________________________________________
Permit Number _______________ Date ____________________________________________
Signature ______________________________ Title __________________________________
Printed Name __________________________________________________________________

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