Clone of BJHS - ACH Authorization

Authorization for Direct Payment
As outlined in your service agreement with EmpowerED Solutions, payments for our services are processed automatically on a bi-monthly basis—specifically on the 10th and 25th of each month. To streamline this process and ensure timely payment, we kindly request that you complete the secure banking information form below. This will authorize EmpowerED Solutions to process payments for your invoices automatically according to the agreed schedule.
Banking Information
Organization Legal Name*
Bank Name*
Name(s) on Bank Account (business name if used)*
Routing Number*
must be 9 numbers - no spaces
Account Number*
Authorization
Authorized Signatory Name & Title*
Signature*

Clear
Date*

MonthDayYear
Date
By submitting this form, you authorize EmpowerED Solutions to initiate automatic ACH debits from the bank account listed above for payment of invoices related to services rendered. These debits will occur on the 10th and 25th of each month, in accordance with your service agreement.

All banking information provided will be stored securely and used solely for the purpose of processing payments for goods and services provided by EmpowerED Solutions. You may revoke this authorization at any time by providing written notice at least 10 business days prior to a scheduled debit.
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Authorization for Direct Payment