AUTHORIZATION FORM FOR DIRECT DEPOSIT ACH CREDITS

AUTHORIZATION FORM FOR DIRECT DEPOSIT ACH CREDITS
Effective March 1, 2007, PHA requires that all HAP payments be made by direct deposit.
I (we) hereby authorize PLANO HOUSING AUTHORITY, hereinafter called PHA, to initiate credit entries for (Application) to my (our) account indicated below and the financial institution named below, hereinafter called FINANCIAL INSTITUTION, to credit the same to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law.

Original Set upBank Account Change
Financial Institution Name
Financial Institution Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
*Type of Account (check one below):

CheckingSavings
*Name on Account:
*Routing Number: Use a check, not a deposit slip to get this number*
*Account Number:*
*Print Individual/Company Name:
Last four of Owner Social Security or Federal Employer ID
*Signature:

Clear
*Date:

MonthDayYear
Date
Owner Name if different than above:
Phone Number

Area CodePhone Number
Email - This is where payment confirmations will be sent:*
example@example.com
Tenant Name or Address of assisted unit:
Take a photo of the check if you are not sure which numbers are the routing / account. The photo will upload with the form.
This authority is to remain in full force and effect until PHA has received written notification from me (or either of us) of its termination in such time and manner as to afford PHA and FINANCIAL INSTITUTION a reasonable opportunity to act on it.
Should be Empty: