Direct Deposit Agreement Form

Direct Deposit Agreement Form
Authorization Agreement
I hereby authorize Perception Funding to initiate automatic deposits to my account at the financial institution named below. I also authorize Perception Funding to make withdrawals from this account in the event that a credit entry is made in error.

Further, I agree not to hold Perception Funding responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part of my financial institution in depositing funds to my account.
Required Information
Legal Name*
Address*

Mailing Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Bank Information
Name of Financial Institution*
Routing Number*
CheckingSavings
Account Number*
Authorized Signature (Primary)*
Date*

MonthDayYear
Date
Authorized Signature (Joint)
Date

MonthDayYear
Date
Ministry Name*
Ministry Partner Code Word
Selected by you in your application - 501c3 nonprofit partners do not need a code word.
Please attach a voided check (checking account) or deposit slip (savings account)*

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