AUTHORIZATION AGREEMENT FOR DIRECT PAYMENT
(ACH DEBITS)
I (we) hereby authorize CFCC Foundation, Inc. to initiate debit entries to my (our)
Checking
Savings account (select one) indicated below at the depository financial institution stated below, hereinafter called DEPOSITORY, and to debit the same such account.
Depository Name
Branch
City
State
Zip
Routing Number
Accounting Number
Amount of Monthly Debit
(select one) 1st
15th of each Month
This authorization is to remain in full force and effect until CFCC Foundation, Inc. has received written notification from me (or either of us) of its termination in such a time and in such a manner as to afford CFCC Foundation, Inc., and DEPOSITORY a reasonable opportunity to act on it.
Initiator Name
Signature
Additional Name(optional)
Signature
Date Note: all written debit authorizations MUST provide that the receiver may revoke the authorization only by notifying the originator in the manner specified in the authorization.Cancellation can be done with a 30 day written notice.To initiate the debit authorization complete form, and mail a printed hard copy with a voided check to:
Ms. Wendy Warner CFCC Foundation Inc. PO Box 1388 Ocala, FL 34478-1388
