Checking Savings. The authority is to remain in full force until The Diocese of Sioux City has received written notification of its termination in such timely manner as to afford the Diocese and the Financial Institution a reasonable opportunity to act on it. Signature: Printed Name: Date: Bookkeeper Contact Info: Bookkeeper Name: Email: Bookkeeper Phone: Fax: Please submit this form and a voided check (or photocopy of a check) to Xxxxxxx Xxxxxxx at xxxxxxxx@xxxxxxxxx.xxx or fax to: 000-000-0000 #N/A
Checking Savings. This authorization is to remain in full force and effect until COMPANY has received notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DFI a reasonable opportunity to act on it. Name(s) Signed Date Customer Telephone # Customer email address *DISTRICT USE ONLY – SERVICE ACCOUNT # Note: All written credit authorizations should provide that the receiver may revoke the authorization only by notifying the originator in the manner specified in the authorization.
Checking Savings. This authority is to remain in full force and effect until the city of Xxxxxx has received written notice of its termination in such time and manner as to afford the City of Xxxxxx and Financial Institution a resonable opportunity to act on it. Signature Date
Checking Savings. $ or Full Net Check or Full Net Check This authorization may be cancelled by me at any time.
Checking Savings. This authority is to remain in full force and effect until POLICY RESEARCH, INC., has received written notification from me to terminate ACH/Direct Deposit. Individual or Organization Name Email Address to Receive Deposit Notification Social Security Number or Tax Identification Number Authorized Signer Date Title Joint Account Owner (if applicable) Signature Date Note: Please attach a voided blank check or savings account deposit slip (copies of blank checks and deposit tickets are acceptable) to validate account information.
Checking Savings. The frequency of the ACH Debit will be monthly occurring on the 10th of the month being billed. This authority is to remain in full force and will be effective 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 a reasonable opportunity to act on it. I (we) can stop payment of any entry by notifying my (our) financial institution 3 business days before my (our) account is charged. I (we) understand it is my (our) responsibility to ensure that proper funding is available in my (our) account at the time the COMPANY initiates the ACH Debit. If proper funding is not available, I (we) will be charged the appropriate fees incurred by the COMPANY from the bank plus an administrative fee of $25.00 (twenty five) dollars. I (we) realize this agreement may be terminated by the COMPANY immediately if any debit is not honored by the Financial Institution named for any reason. (Name of Financial Institution) (Branch Address) (City) (State) (Zip) (Transit/ABA/Routing No.) (Bank Account No.) ***** ATTACH A VOIDED CHECK***** Please Print Name(s) (Please Print Address) (Telephone #) (Signature) (Date) Your monthly premium will be deducted from your designated account as per your authorization above. If the premium amount changes, you will receive updated payment coupons reflecting the new premium amount at least 10 days before the ACH debit will occur. Return completed form to: HealthNow Administrative Services, Attn: Implementation, 000Xxxxxxxx Xxxxx, Xxxxx 000, Xxxx Xxxx, XX 00000. Please note this is not the same address where payments are mailed to. The form and voided check can also be faxed to Implementation’s attention at 000-000-0000 or emailed to XXXXxxxx@xxxx.xxx
Checking Savings. This authorization is to remain in full force and in effect until Twin Valleys PPD has received mail, fax or internet notification from me (or either of us) of its termination in such time and in such manner as to afford Twin Valleys PPD and the financial institution entered above opportunity to act on it. Name(s) (Please Print) Signature(s): Date To ensure proper bank coding, please attach a voided check to this form with the bank routing and your account number.
Checking Savings. This authority is to remain in full force and effective until the City and the Depository has received written notification from me (or either of us) of its termination in such time and manner as to afford the City and the Depository a reasonable opportunity to act on it. Customer Signature:
Checking Savings. Indicated below at the depository financial institution named below, referred hereinafter as depository and to credit the same to such account. Depository Name: Branch: City: State: Routing:* Account THIS AUTHORIZATION IS TO REMAIN IN FULL FORCE AND EFFECT UNTIL PHA HAS RECEIVED WRITTEN NOTIFICATION FROM ME OF ITS TERMINATION IN SUCH TIME AND IN SUCH MANNER AS TO AFFORD PHA AND DEPOSITORY A REASONABLE OPPORTUNITY TO ACT ON IT. Account Holder: Fed tax ID #: Date: Signature: ***VALID ID IS REQUIRED TO MAKE DIRECT DEPOSIT CHANGE.*** ***YOU MUST VERIFY THE ROUTING NUMBER WITH YOUR BANK PRIOR TO SUBMITTING FOR PROCESSING*** *ROUTING INFORMATION CAN BE FOUND ON THE BOTTOM OF YOUR PERSONAL CHECK, PRECEDING YOUR ACCOUNT NUMBER, OR ON THE BANK’S LETTER. RETURN TO: The Philadelphia Housing Authority HCV Program Payment Department 0000 Xxxxxxxxxx Xxx.
Checking Savings. This authority is to remain in full force until Northern Local School District has received written notification from me of its termination. Northern Local School District must receive this in a timely manner in which Northern Local School District and the FINANCIAL INSTITUTION have reasonable opportunity to act on it. Name SSN xxx-xx- Signature Date
