ACH TRANSACTIONS AUTHORIZATION AGREEMENT
☐ NEW ☐ REVISE ☐ TERMINATE (Check One)
I (we) authorize [INSERT YOUR COMPANY NAME HERE] to electronically debit my (our) account
(and, if necessary, electronically credit my (our) account to correct erroneous debits) to my ☐ CHECKING ☐
SAVINGS account (Check One) at the financial institution (Bank) named below.
Bank Name ______________________________________________________________________________
Bank Address ____________________________________________________________________________
Routing Number ____________________________ Account Number _______________________________