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ACH Authorization Form
Client Name:
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I am authorizing the following:
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Recurring Monthly Charge
One-Time Charge
Other... (please specify below)
Other... (please specify below)
Authorized Amount:
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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.
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Yes
No
Financial Institution
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Account Type:
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Checking
Savings
Routing / Transit Number
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Account Number
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Authorized Signer's Name:
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Date
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Authorized Signer's Title:
Authorized Signer's Signature
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