Employer Funding Account

Employer Funding Account

ACH Debit Authorization · Complete all required fields
Federal Tax ID (FEIN)
Client Legal Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ACH Authorization Effective Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Banking Information
*Allow up to 5 banking days from the time Clergytech receives this form for processing. Payrolls in progress at the time of this submission will be drafted from the current account on file at the time of processing.
Name of Financial Institution
Maximum Debit Authorization Amount
Enter the maximum dollar amount per debit entry you are authorizing, or enter 'Variable – Payroll Amount' if debits will vary each payroll cycle.
Routing Number
Account Number
Account Type
Bank Verification Document

Upload a voided check OR a bank letter on official institution letterhead. This is required to verify your banking information prior to ACH processing.
Cancelof
Authorization
I hereby certify that I am authorized by the above-named client to act in this matter and, under said authorization, do hereby authorize ChurchPayroll (a division of Clergytech, Inc.) and its agents, including financial institutions, to initiate Automated Clearing House (ACH) electronic debit entries, and if necessary, credit entries and adjustments for any debit or credit entries made in error, to the bank account indicated above. This authorization covers transactions including, but not limited to, salaries, wages, benefits, payroll taxes, garnishments, service fees, and any other transactions ordinary and necessary to the fulfillment of services connected herewith. These services shall be administered in accordance with the Terms of Service (TOS) of ChurchPayroll as currently in effect and any superseding amendments. This authorization shall remain in effect until revoked in writing. To revoke this authorization, written notice must be provided to ClergyTech, Inc. at least three (3) business days prior to the next scheduled debit entry. ClergyTech, Inc. must be given a reasonable opportunity to act on the revocation. Records of this authorization will be retained for a minimum of two (2) years following termination or revocation, in accordance with Nacha Operating Rules.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Submitter's Name and Title
Submitter's Email
example@example.com
Secured by ClergyTech · 1-800-662-3454 · churchpayroll.com
Should be Empty:

Employer Funding Account

Banking Information

Authorization