ATM Headquarters ACH Authorization Form
This form will allow us to return to you and deposit your fill cash (daily) used to operate your ATM, your ATM surcharge revenue earnings (monthly), and any miscellaneous fees according to your agreement.
Are you a new customer or are you changing information for an existing machine? (Choose only one)
Changing an existing bank account? Choose if this is for daily cash replacement, your monthly surcharge payments or both below.
Setting up a new account.
What are we using this bank account for? (Choose Only One)
ATM daily cash replacement and monthly surcharge to the same bank account.
ATM daily cash replacement only.
ATM monthly surcharge only.
I want my ATM fill cash and ATM surcharge payments deposited to two different bank accounts. Select this option to have an additional ACH generated on the second part of this form for the Surcharge payments to a 2nd different bank account.
First Bank Account
Information required to send your operating cash back to your bank daily. If you would like your cash replenishment and your monthly Surcharge payments both going to the same account select the first box "ATM fill cash and monthly surcharge to same account" above.
The Corporate Legal Business Name or Person if a sole proprietorship or individual authorizing the use of this bank account.
Location Name (DBA: The Name on the sign of the business where the ATM is Located)
Location Address
Location City
State
Zip
Phone
Format: (000) 000-0000.
Location Contact
The Person who is signing this document who is authorized by the above named company to sign. (Can be the same person as above if is a sole proprietor or individual)
The above named entity authorizes Payment Alliance International, Inc., or its designated assignee, referred to as PAI, to initiate ACH transfer entries and to debit and/or credit the account identified herein for all Processing Services. This authorization shall remain in effect unless and until PAI has received written notification from ATM Operator that this authorization has been terminated in such time and manner to allow PAI to act. PAI and ATM Operator agree and acknowledge that PAI has the right, title and interest in and to credit and debit Account for the settlement of Terminal transactions and transaction adjustments on behalf of ATM Operator. ATM Operator agrees to comply with all electronic-fund-transfer network rules, regulations and requirements. ATM Operator has the authority to authorize PAI to process their ATM transactions and enter into this agreement. ATM Operator shall hold PAI harmless and indemnify, including attorney fees, in the event of a claim. ATM Operator acknowledges and understands that any relationship established between ATM Operator and PAI is related to that certain Independent Sales Representative Agreement (the “Agreement”) between PAI and the independent sales representative with whom you have contracted. Accordingly, ATM Operator agrees that PAI shall have no further obligations to ATM Operator, of whatever sor or nature, if the Agreement terminates for whatever reason. For Settlement on behalf of ATM Operator’s Terminals and for payment of Expenses due and owing under this Agreement, ATM Operator shall establish and maintain an ACH Account. Settlement on non-banking days is held in queue at processor until the bank system opens for business. ATM Operator further agrees to maintain at all times in ATM Operator’s ACH Account a balance sufficient to pay all amounts due and owing to PAI under this Agreement. It is the responsibility of the ATM Operator to verify that all information contained in the exhibits and all other forms submitted by ATM Operators to PAI or any modification thereof is correct and complete. PAI has no responsibility to verify any such information and will not be responsible for any Expenses, claims, damages, liability, loss, demands or any causes of action arising out of or related to any incorrect information submitted to PAI or any notice of change related thereto. ATM Operator shall audit and balance the data contained in the periodic statements and summary reports provided by PAI and shall promptly notify PAI of any disputed item or items on such periodic statements and summary reports. All shortages and adjustments must be reported to PAI within 7 days or ATM Operator assumes full liability. If following ATM Operator’s timely notice PAI determines that the disputed item was credited or debited in error by PAI, PAI shall use commercially reasonable efforts to correct the error. However, PAI shall not be liable for any damages, interest or Expenses associated with any error by PAI or for recovery of any amounts which were transmitted in error over thirty (30) days prior to the date PAI receives notice from ATM Operator. In such event, PAI will use commercially reasonable efforts, but shall be under no obligation to incur any Expense, to recover the same on ATM Operator’s behalf.
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Month
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Day
Year
Date
Signature
Bank Name
Bank Branch Address - if available
City
State
Zip
Account Type (Check Only One)
Checking
Savings
Name on the bank account (This name must match bank account records for this account)
Bank Routing Number
Bank Account Number
Would you electronic like access to transaction reports for your ATM?
If so please create a user name and an email address to receive a login link
Create a User Name
Enter an Email to use for this user name
example@example.com
Second Bank Account
Information required to send Surcharge Payments to a different Account than the daily ATM Cash replacement as selected above. Complete the bank information below. If you would like your cash replenishment and your monthly Surcharge payments both deposited to the same account, select the first box "ATM fill cash and monthly surcharge to same account" at the top of this form. If You prefer to receive a written check mailed to you, check the "Mail Me a Check" box below. NOTE: All accounts electing a paper check mailed will be charged a $20.00 monthly check processing fee.
I want to receive a paper check mailed to me. I understand there is a $20.00 monthly charge for this method of payment.
Mail me a check
Are you changing information for an existing machine (Check only One)
Changing an existing account?
Setting up a new Account
Bank Name
Bank Branch Address (if available)
City
State
Zip
Account Type (Check Only One)
Checking
Savings
Name on the bank account (This name MUST match bank account records for this account)
Bank Routing Number
Bank Account Number
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