AUTHORIZATION FOR DIRECT DEPOSIT VIA ACH

I hereby authorize SCCE & HCCA to electronically credit my account (and, if necessary, to electronically debit my account for any transactions credited in error) for all payments (i.e. honorariums, expense reimbursements and/or services rendered), in lieu of receiving a printed check.

Select One:

Checking Account (voided check or copy of voided check must be attached)

Savings Account (bank document must be attached)

Bank Name

Bank Address

Routing Number

Account Number

Name(s) on Your Account

E-mail Address for Notifications

Upload a Blank Check

One file only.
20 MB limit.
Allowed types: gif, jpg, png, pdf.

I understand that this authorization will remain in full force and effect until I notify SCCE & HCCA in writing to SCCE & HCCA’s CFO that I wish to revoke this authorization.

I understand that in order to keep the administration process relating to ACH Credit to a minimum, I will not be able to elect to receive certain payments by ACH Credit and others by printed check.

I do not intend to revoke this authorization prior to calendar yearend. In other words, I intend to elect ACH Credit for the long-term.

I agree to the terms of service.

I agree to the {terms of service}.

Signature

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