ACH Authorization

Grain Settlement ACH Enrollment Form

ProVision Partners Cooperative • Allied Cooperative®
Grain customers with active lien notices are not eligible for ACH payments.

Information on the form is subject to additional verification. All fields must be completed to process. Please allow 5 business days for ACH to be in effect.
Customer Information
Account Name:*
Name on your co-op account
Account #:*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
Please enter a valid phone number.
Contact Name:*

First NameLast Name
Email Address for Settlement Notices:*
example@example.com
Financial Institution Information
Bank Name:*
Bank Phone #:*
Please enter a valid phone number.
Bank Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name(s) on Bank Account (business name if used):*
Routing Number:*
must be 9 numbers - no spaces
Account Number:*
must be 6-12 numbers - no spaces
Type of Bank Account:*

Personal CheckingBusiness Checking
Authorized Name:*
Title:*
Date:*

MonthDayYear
Date
Authorized Signature:*

Clear
Enter the message as it's shown*
Please submit completed form with a copy of a voided check by uploading below.
Voided Check Upload:*

Cancelof
Comments or Concerns:
Should be Empty:

Grain Settlement ACH Enrollment Form