Commission Statement Recipient Information
Agency Name
*
Tax ID / FEIN
*
Commission Statement Recipient
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
ACH Payment Authorization
Please complete the information below to switch the disbursement method for your commissions. You will be notified by email when the first direct deposit disbursement is made.
Bank Name
Account Type
Checking
Savings
Bank Account #
Bank Routing #
ACH Acknowledgement
I understand that this authorization will remain in effect until I cancel it in writing and I agree to notify AmFed in writing of any changes to my account information or termination of this authorization at least 15 days prior to the next disbursement date. If commission transactions fall on a weekend or holiday, I understand that the payments may be executed on the next business day. I acknowledge that the origination of ACH transactions to the account above must comply with the provisions of U.S. law. I certify that I am an authorized user of this bank account and will not dispute these scheduled transactions with my bank; so long as the transactions correspond to the terms indicated in this authorization form.
Signature - Use your Mouse or Finger to execute your signature below.
Agency Representative Authorizing ACH Commission Transactions
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Submit
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