AUTHORIZATION AGREEMENT FOR AUTOMATIC DEPOSITS 

                                                                      (ACH CREDITS)

                      Originating Company Name:   DISTRICT 2 PUBLIC HEALTH

 

I authorize the above named originating company to initiate entries to the account indicated below as follows:

 

They may initiate CREDIT entries, which moves money into my account according to the schedule and conditions  to which the originating company and I have agreed.

They may initiate DEBIT entries to reverse any transactions they have originated to my account in error.

 NAME(S)_______________________________________________________________

                                                     (Please Print)

ACCOUNT NUMBER_______________________________________________________

                                        NAME OF DEPOSITORY

FINANCIAL INSTITUTION:_________________________________________________

                       LOCATION OF DEPOSITORY FINANCIAL INSTITUTION:

 

CITY:_______________________STATE___________________________ZIP________

Please enter your banks’ routing and transit number below OR staple a VOIDED CHECK.

                                           ___  ___  ___ ___ ___ ___ ___ ___ ___

This authority is to remain in effect until the Originator has received written notification of its termination and has had a reasonable opportunity to act upon it.

 

DATE____________________SIGNED________________________________________

 DO NOT USE A DEPOSIT SLIP.  Many banks print internal transaction codes instead of their routing and transit numbers on their deposit slips.  Using an invalid routing and transit number will prevent your transaction from being directed to the correct bank, resulting in delays in the posting of your payment.