Fill in below for ACH Authorization
Today's Date
-
Month
-
Day
Year
Date
Start Payment
*
-
Month
-
Day
Year
Choose date to start auto payments
Payment Amount
*
Monthly amount to be drafted including Property Taxes
Account Type
*
Personal Checking
Business Checking
Personal Savings
Business Savings
Customer Name
*
First Name
Last Name
Farm Location
*
Syrup Mill Farms
Bramlett Farms
Springfield Farms
Edwards Farms
Eli Knob Farms
Bethany Church Farms
Sandy Creek Lane
Herds Creek Rd
Shady Farms
Siloam Farms
McIntyre Farms
Your Farm Location
Farm Number
*
A
B
C
1
1-B
2
2-B
3
3-B
4
4-B
5
5-B
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
Your Farm Number
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Email
*
Confirmation Email
Primary Phone
Format: (000) 000-0000.
Blank Check Photo
*
Click to Upload Photo
Cancel
of
Customer Signature
Desktop sign with mouse | Mobile sign with finger
Please verify that you are human
*
Submit
Clear
Should be Empty: