DIRECT DEPOSIT FORM

AUTHORIZATION AGREEMENT FOR ACH CREDITS (DIRECT DEPOSITS)

I (WE) hereby authorize YOUR COMPANY NAME GOES HERE. hereinafter called COMPANY, To initiate credit entries and/or correction entries to my / our Account (select one) indicated below at the depository named below, hereinafter called DEPOSITORY, to credit the same to such account.


Bank Name:

Branch:

Routing / Transit Number (First 9 Numbers on Left)
Branch Location

State:

Account Number (Usually on Right)

Optional: Photo of Deposit Slip:

CheckImg


This authorization is to remain in full force until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY reasonable opportunity to act upon it.