Authorization Agreement Form For Direct Deposits (Ach Credits) printable pdf download

Authorization Agreement Form For Direct Deposits (Ach Credits)

AUTHORIZATION AGREEMENT FOR DIRECT DEPOSITS (ACH CREDITS)

Carrier

Name_______________________________________

ID Number_____________________________________

The

)________________________________________________________________________________

(Carrier Name

hereby authorizes the Alabama Wireless 9-1-1 Board, hereinafter called COMPANY, to initiate credit entries to its

checking account,

savings account (select one) indicated below at the depository financial institution named

below, hereinafter called DEPOSITORY, and to credit the same to such account.

The

________________________________________________________________________________

(Carrier Name)

acknowledges that the origination of ACH transactions to its account must comply with the provisions of U.S. law.

Depository

Name_______________________________________

Branch

______________________________

(If applicable)

City________________________________________

State_____________________Zip__________________

Routing

Account

Number_____________________________________

Number_______________________________________

This authorization is to remain in force and effect until COMPANY has received written notification from the

authorized individual named below of its termination in such time and in such manner as to afford COMPANY and

DEPOSITORY a reasonable opportunity to act on it.

Authorized Signer____________________________________________________________________

(Please Print)

Signature________________________________________ Date______________________________

NOTE: ALL WRITTEN CREDIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY

REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER

SPECIFIED IN THE AUTHORIZATION.

Authorization Agreement Form For Direct Deposits (Ach Credits)