EFT Debit Authorization Form

Authorization Agreement for Direct Payments

Electronic Transfer of Funds (ETF)
I (we) hereby authorize First Name Last Name hereinafter called COMPANY to initiate debit entries to my (our) Checking Account Savings Account (select one) indicated below at the depository financial institution named below, hereinafter called DEPOSITORY, and to debit the same to such account. I (we) acknowledge that the origination of ACH transaction to my (our) account must comply with the provision of U.S. Law.
Financial Institution

Your Financial Institution Name Your Financial Institution Branch
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Routing Number Re-enter Routing Number
Account Number Re-enter Account Number
I understand that a withdrawal will take place on approximately the 3rd of each month. If there are insufficient funds, it will be sent through a second time. If it is still a NSF amount, a NSF charge will occur for each insufficient fund occurrence. 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 manner as to afford COMPANY and FINANCIAL INSTITUTION a reasonable opportunity to act on it.
Your Individual Name First Name Last Name
Your Signature Signature Date
Your Child's Name First Name Last Name Date Date
*NOTE: DEBIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION.
Should be Empty:

Authorization Agreement for Direct Payments