Clients Authorization for Direct Deposit

Clients Authorization for Direct Deposit via ACH (ACH Credit)

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CONSUMER AUTHORIZATION FOR DIRECT DEPOSIT VIA ACH (ACH CREDITS)

Direct Deposit via ACH is the deposit of funds to a consumer’s account, for example, payroll, employee expense reimbursement, government benefits, tax and other refunds, annuities, and interest payments.

I (we) hereby authorize BACKOFFICE ASSIST to electronically credit my (our) account (and, if necessary, to electronically debit my (our) account to correct erroneous credits1) as follows:

Select One

Checking Account

Savings Account

at the depository financial institution named below (“DEPOSITORY”). I (we) agree that ACH transactions I (we) authorize comply with all applicable law.

Depository Name

Routing Number

Account Number

Name(s) on the Account

Amount of credit(s) or method of determining amount of credit(s)

Date(s) and/or frequency of credit(s)

I (we) understand that this authorization will remain in full force and effect until I (we) notify COMPANY [insert manner of revocation, i.e., in writing, by phone, location, address, etc.] that I (we) wish to revoke this authorization. I (we) understand that COMPANY requires at least [X

Enter the amount you wish to pay:

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