Form Authorization Agreement For Direct Deposit - Community National Bank
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1A
A
UTHORIZATION
GREEMENT
COMMUNITY
F
D
D
OR
IRECT
EPOSIT
NATIONAL
Effective 5/2015
225 Main Street ● PO Box 225 ● Seneca KS 66538
BANK
Phone: (800)680-0340 ● Fax (785)336-2214
R
P
D
ETIREMENT
LANS
IVISION
CNB Account Number _________________ Account Name ____________________________________
I. BANK ACCOUNT INFORMATION
COMPANY NAME: Community National Bank
COMPANY ID NUMBER: 101104504
I hereby authorize Community National Bank, hereinafter called COMPANY, to initiate credit entries and to initiate, if
necessary, debit entries and adjustments for any credit entries in error to my account indicated below and the financial
institution named below, hereinafter called FINANCIAL INSTITUTION, to credit and/or debit the same to such account. I
acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law.
BANK NAME __________________________________________PHONE____________________________________
CITY ________________________________________________ STATE ____________ ZIP ____________________
ABA ROUTING # __________________________________ ACCOUNT # ___________________________________
Your Bank’s ABA Routing Number (9 digits) AND Your Account Number MUST Be Provided!!
II. ACCOUNT TYPE
Checking (attach voided check below)
Savings (attach verification from bank or savings statement)
III. VOIDED CHECK
JOHN DOE
9999
123 FOURTH AVENUE
ANYTOWN, USA 12345
DATE_____________
PAY TO THE
________________________________________________________$
ORDER OF
Dollars
________________________________________________________________________________________________
YOUR FINANCIAL INSTITUTION
ANYTOWN, USA 12345
MEMO_____________________
_______________________________________
:123456789:
012345678901
9999
IV. SIGNATURE
This Authority is to remain in full force and effect until COMPANY has received written notification from me of its
termination in such time and such manner as to afford COMPANY and FINANCIAL INSTITUTION a reasonable
opportunity to act on it.
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.
X______________________________________________________
_________________________
Signature of Account Owner
Date
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