Microsoft Word - ACH Authorization Form - FI's

AUTOMATED CLEARING HOUSE (ACH) AUTHORIZATION FORM

Information:

Financial Institution
Name:

Remittance Address:

Remittance City: State: Zip Code:

Contact Name: Phone #: ( )

E-Mail Address:

Banking Information:

Bank Name:

Bank Address:

Bank’s City: State: Zip Code:

Bank Contact Name: Phone #: ( )

ABA Routing #: Account #:

Account Type
(please check only one)

Authorization:

Please sign below to confirm that you are authorizing Autobooks, Inc to begin transferring payments to the account mentioned above. All questions and requests can be sent to accounting@autobooks.co or call (313)774-2445

Signature
( )

Phone Number
Title
Date

*Additional Verification: Previous Bank Account # (if applicable): ________________________