ACH - Mountain Vista Metropolitan District

Mountain Vista Metropolitan District

Authorization Agreement for Direct Deposits (ACH Debits)
I (we) hereby authorize Mountain Vista Metropolitan District (and/or its duly authorized Manager), hereinafter called the DISTRICT, to initiate Debit entries to my (our) Checking Account indicated below at the depository financial institution named below, hereinafter called the DEPOSITORY, and to Debit the amount of the District’s quarterly Trash Service and Recreation Center Dues billing 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.
Who do you Bank with? - DEPOSITORY NAME:*
Name of your Bank
BRANCH
(ie: Chase Bank is a branch of JP Morgan)
CITY*
STATE*
ZIP
ROUTING NUMBER*
ACCOUNT NUMBER*
* The routing number and bank account information can be found on a check for the account as shown on the picture below. If you want to insure that the above information is correctly entered, you may attach a voided check or a cancelled check to the District from a previous payment.
This authorization is to remain in full force and effect until the DISTRICT has received written and signed notification from me (or either of us) of its termination in such time and in such manner as to afford the DISTRICT and the DEPOSITORY a reasonable opportunity to act on it.
NAME(S) ON ACCOUNT*
PRINTED NAME - Authorizing ACH*
MOUNTAIN VISTA ACCOUNT #*
SERVICE ADDRESS*
Phone Number*
Please enter a valid phone number.
Note: All written Debit authorizations should provide that the receiver may revoke the authorization only by notifying the originator in the manner specified in the authorization.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: