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 Contact Xxxxx at 000-000-0000 or Xxxxxxx at 000-000-0000 if questions. Thanks.
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. $ 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 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. 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, PO Box 742, Blue Bell, PA 19422. 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 effect until Xxxx X. Xxxxxxx, DMD, PA has received written notification from of its termination in such time and in such manner as to afford Xxxx X. Xxxxxxx, (your name) DMD, PA a reasonable opportunity to act on it.
Checking Savings. May Be Subject To Identity Verification To help ensure the security of your account and funds, once your request is received, the Company may be obtaining a consumer report from a consumer reporting agency (“CRA”) to help verify the validity and accuracy of the account information provided. I authorize the Company to obtain a consumer report from a CRA as described above, and acknowledge that I: (i) have read the explanation above; (ii) understand that in order for the CRA to verify my account information, some of my personal information will be shared with the CRA in the strictest confidence and as permitted by law and will be retained and used by the CRA only as permitted by law; and (iii) consent to such sharing, retention and use. Name Name of Financial Institution Agent Number Name of Account Holder Tax ID/Social Security Number Routing/ACH Number Signature (Required) Account Number Signature Requirements:
Checking Savings. This authority is to remain in full force and effect 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 a reasonable opportunity to act on it. NAME(S) - Please Print A/R EMAIL ADDRESS ADDRESS CITY/STATE ZIP CODE AUTHORIZED SIGNATORY DATE Please complete this form and return it to x-xxxxxxxx@xxxx.xxxxxx.xxx Headquarters: 00-0000 Xxxxxxxxx Xxxxxxx, Xxxxxxx, XX 00000 Phone (000) 000-0000 ⚫ Fax (000) 000-0000
Checking Savings. This authorization is to remain in full force and effect until City of Westland has received written notification from me/either of us of its termination in such time and such manner as indicated on the reverse of this authorization. Name(s) (please print) Signature(s) Date NOTE: ALL DEBIT AUTHORIZATIONS MUST PROVIDE THAT THE CUSTOMER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE CITY OF WESTLAND IN THE MANNER SPECIFIED IN THE AUTHORIZATION. NOTE: It may take up to two billing cycles before automatic payments begin.
