PLEASE ATTACH A VOIDED CHECK. This authorization is to remain in full force and effect until Trimark Corporation has received written notification from me of its termination in such time and in such manner as to afford Trimark Corporation a reasonable opportunity to act on it. Under penalties of perjury, I (we) certify that the Name and Signature(s) are authorized signers to the Depository (Bank) Name. (Please complete & return to xxxxxxxxxxxx@xxxxxxxxx.xxx or fax 000-000-0000.) Signed: Date: NOTE: ALL WRITTEN DEBIT AUTHORIZATION MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION. Internal Use Only: EFT Networks Data Entry Code: Data Entry Date: Last Edit 7/25/21 ACH Debits & Online Payments Are Now Available…. Trimark Corporation invites you to take advantage of our new payment options: OPTION #1 = ACH DEBIT PROGRAM BENEFITS Sign up today for electronic ACH debits from your account. This option is FREE OF CHARGE to you and only takes one form to complete the signup. The following are some of the key benefits for signing up for ACH Debits: All monthly dues will be automatically drafted from your account on 1st of month ACH Form on Reverse Side Ensures timely receipt of payments….never worry about late charges again! Save on postage No more lost payments in the mail No more hassles with writing checks HOW TO ENROLL? It’s easy to sign up! Simply complete the attached ACH form (on the back of this notice). Please don’t forget to sign & attach a voided check. If you don’t have your Trimark Account#, simply leave it blank and we will fill it in for you. Return via Submit option, email at Xxxxxxxxxxxx@xxxxxxxxx.xxx or fax to 703‐940‐4441. Lost your form? That’s ok, just visit xxx.XxxxxxxXX.xxx and print one under Client Portal. OPTION #2 = ONLINE PAYMENTS BENEFITS Online payments are now accepted! All major credit cards and e‐check payments can be by registering your email through our online portal and processed by PAYLEASE* (*3RD PARTY PROCESSING FEES APPLY) HOW TO ENROLL? Visit our website at xxx.XxxxxxxXX.xxx Click on “Make a Payment” (top right hand corner) Register by entering your Acct ID* (please email xxxxxxxxxxxx@xxxxxxxxx.xxx to obtain this information for initial registration) Customer support: (866) 729‐5327 or Xxxxxxx.XxxXxxxx.xxx 0000 Xxxxxxxx Xxxx, Xxxxx 000 ♦ Falls Church ♦ Virginia ♦ 00000-0000 ♦ Telephone: 000.000.0000 ♦ Facsimile: 703.940.4441
PLEASE ATTACH A VOIDED CHECK. This authorization shall be effective as toGolden Oil Company, LLC’s invoices dated on or after and shall remain in effect until terminated upon thirty (30) days written notice by Customer to Golden Oil Company, LLC 0000 Xxxxxx Xxx. Xxxxxxxxxx, Xxxxxxxxx 00000. Notice of termination shall in no way affect credit transactions initiated prior to the actual receipt of notice. It is understood that this authorization agreement is subject to continuing credit approval by Golden Oil Company, X.XX Authorized this day of 20. By: Title: Approved and accepted this day of 20. Golden Oil Company, LLC By:
PLEASE ATTACH A VOIDED CHECK. Return the completed form to: P.O Box 925688 Houston, Texas 77292-5688 Comments: AUTHORIZATION TO HONOR DEBITS DRAWN BY COMPANY REFERENCED ABOVE To: (Print Name and Address of Financial Institution where Account is maintained) As a convenience to me, I hereby request and authorize you to pay and charge to my account debits drawn on my account by and payable to the order of – the company referenced above - provided there are sufficient collected funds in said account to pay the same upon presentation. This authorization will remain in effect until revoked by me in writing, and until you actually receive such notice I agree that you shall be fully protected in honoring any such debit. This arrangement shall terminate immediately upon the closing of my account with you or upon receipt by you of notice of my bankruptcy. I agree that your treatment of and rights in respect to each such debit shall be the same as if it were signed by me. I further agree that if any such debit be dishonored, whether with or without cause and whether intentionally or inadvertently, you shall be under no liability whatsoever, even though such dishonor results in the forfeiture of insurance.
PLEASE ATTACH A VOIDED CHECK. If applicable, I will be charged a fee according to the Credit Union’s published schedule for this service. I understand that if sufficient funds are not available on the scheduled date I may be charged a fee by both the Credit Union and the other Financial Institution, and that my loan, if any, may become delinquent.
PLEASE ATTACH A VOIDED CHECK. CANCELLATION I hereby cancel the authorization for the Cathedral of St. Xxxxxx to originate Debit entries to my checking/savings account indicate above, effective on . Signed: Date:
PLEASE ATTACH A VOIDED CHECK. TO EXPEDITE THE PROCESS ! The bank ABA or routing DO NOT include any dashes (-) number will be 9 digits. in your bank account number. : 101010011: 0551005115100 1101 Vendor: Prenote Date: Bank Table Code ACH Status 23 or 33 District Approval: Comments: Auditor-Controller's Office Use Only Rev. 11/1/2019 COUNTY OF NEVADA VENDOR DATA RECORD VENDOR # (Required when receiving payment from the County of Nevada in lieu of IRS W-9) STD. 204 (Rev. 8-2010) 1 Please Return this form to: For Electronic Deposit contact: XX.Xxxxxxx@xx.xxxxxx.xx.xx or Call (000) 000-0000 2 PAYEE’S LEGAL BUSINESS NAME (Type or Print) SOLE PROPRIETOR – ENTER NAME AS SHOWN ON SSN (Last, First, M.I.) E-MAIL ADDRESS MAILING ADDRESS PHONE NUMBER CITY, STATE, ZIP CODE FAX NUMBER 3 PAYEE ENTITY TYPE CHECK ONE BOX ONLY NOTE: Payment will not be processed without an accompanying taxpayer I.D. number ENTER FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN): - PARTNERSHIP CORPORATION: ESTATE OR TRUST Professional Services Nevada County Employee Employee # Rent / Landlord Merchandise MEDICAL (e.g., dentistry, psychotherapy, chiropractic, etc.) LEGAL (e.g., attorney services) EXEMPT (nonprofit) ALL OTHER CORPORATIONS / LLC’S Other INDIVIDUAL OR SOLE PROPRIETOR ENTER SOCIAL SECURITY NUMBER: - - (SSN required by authority of California Revenue and Tax Code Section 18646) 4 PAYEE RESIDENCY STATUS California resident - Qualified to do business in California or maintains a permanent place of business in California. California nonresident (see reverse side) - Payments to nonresidents for services may be subject to State income tax withholding. No services performed in California. Copy of Franchise Tax Board waiver of State withholding attached. 5 I hereby certify under penalty of perjury that the information provided on this document is true and correct. Should my residency status change, I will promptly notify the State agency below. AUTHORIZED PAYEE REPRESENTATIVE’S NAME (Type or Print) TITLE SIGNATURE DATE TELEPHONE
PLEASE ATTACH A VOIDED CHECK. NOTES: This authorization is to remain in full force and effect until Steuben County receives written notification from me (or either of us) of its termination. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law. Signature (s) Date
PLEASE ATTACH A VOIDED CHECK. Name on the Other Financial Institution Account:
PLEASE ATTACH A VOIDED CHECK. (DEPOSIT SLIPS DO NOT ALWAYS HAVE THE CORRECT TRANSIT ABA ROUTING#. WE CANNOT CREDIT YOUR ACCOUNT WITHOUT A VOIDED CHECK.) RETURN THIS COMPLETED AND SIGNED AGREEMENT, ALONG WITH THE ABOVE DOCUMENTS, TO: BENEFIT ADMINISTRATION COMPANY P.O. BOX 550 SEATTLE, WA 98111-0550 (000) 000-0000 Fax
PLEASE ATTACH A VOIDED CHECK. (Do Not attach a deposit slip) Name (as shown on bank account) Address City/State/ Zip Home Phone/ Daytime Phone / Student Name/ Grade / Checking Savings FINANCIAL INSTITUTION TRANSIT ROUTING NUMBER BANK ACCOUNT NUMBER I authorize Saint Xxxxxx Catholic School to automatically deduct my monthly EDP Tuition Payments from the above referenced account. I understand that this authorization will remain in effect until I provide written notice of termination in such a time and in such a manner as to afford Saint Xxxxxx Catholic School a reasonable opportunity to act on it (a minimum of 7 business days’ notice prior to effective date). I understand that it is my responsibility to notify Saint Xxxxxx Catholic School of any changes in student(s) enrollment. I understand that Saint Xxxxxx Catholic School reserves the right to terminate this service at any time. / / SIGNATURE (Required for validation) DATE
