City of LaFayette

Authorization Agreement for Direct Payments (ACH Debits)

NOTE:  PLEASE ATTACH A VOIDED CHECK WHEN SUBMITTING THIS FORM AT CITY HALL.

Company name_________________________________      Company ID number_______________

I (we) hereby authorize City of LaFayette hereinafter called, COMPANY, to initiate debit entries to my (our) ___ checking account  ___ savings account (select one) indicated below at the depository financial institution named below, hereafter called DEPOSITORY, and to debit the same to such account.  I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law.

Depository name_____________________________          Branch___________________________

City__________________________                    State_____________                Zip__________

Routing number_________________________         Account number_________________________

This authorization is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of  its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.

Name(s)____________________________           Account number___________________________

                           (please print)

Name  _____________________________

Date__________________________                   Signature______________________________

NOTE:  DEBIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION.

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