Bank Draft Authorization
I,_______________________hereby authorize mindFULL, P.A., hereinafter called COMPANY, to initiate debit entries to my account indicated below and the financial institution named below, hereinafter called FINANCIAL INSTITUTION, to debit the same to such account. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law.
________________________________________________________________________
Financial Institution Name Branch Location
________________________________________________________________________
Address City/State Zip
_________________ _____________________ Type of Acct: ____Checking ____ Savings
Routing Number Account Number
This authority is to remain in full force and effect until COMPANY has received written notification from me of its termination in such time and manner as to afford COMPANY and FINANCIAL INSTITUTION a reasonable opportunity to act on it. A 60-day written notice is required.
_______________________________ ________________________________
Print Individual Name Signature
_______________________________ ________________________________
Date Date debits to start/AMOUNT/Initials
PLEASE ATTACH COPY OF VOIDED CHECK TO THIS FORM
________________________________________________________________________
Financial Institution Name Branch Location
________________________________________________________________________
Address City/State Zip
_________________ _____________________ Type of Acct: ____Checking ____ Savings
Routing Number Account Number
This authority is to remain in full force and effect until COMPANY has received written notification from me of its termination in such time and manner as to afford COMPANY and FINANCIAL INSTITUTION a reasonable opportunity to act on it. A 60-day written notice is required.
_______________________________ ________________________________
Print Individual Name Signature
_______________________________ ________________________________
Date Date debits to start/AMOUNT/Initials
PLEASE ATTACH COPY OF VOIDED CHECK TO THIS FORM