ACH Authorization Form

I am authorizing the following: *
I (we) hereby authorize FAULKNER MOSCA & ASSOCIATES PLLC (herein "Company"), to debit/credit entries to my (our) account indicated above and the Financial Institution named below (herein "Financial Institution") to debit/credit the same to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of the U.S. Law.

The authority is to remain in full force and effect until Company has received written notification from me of termination in such time and manner as to afford Company and Financial Institution a reasonable opportunity to act on it. *
Account Type: *
Authorized Signer's Signature *