Authorization Agreement for ACH Debits
If you would like to authorize Fred Hamm Inc. to deduct your monthly payments by automatic deduction please: 1. Complete the form below. If your account is a joint account both account holders must sign this form. 2. Attach a voided, unsigned check to the form. 3. Return the original form and the voided check to Fred Hamm Inc. We will process your account for automatic deduction as soon as we receive your form.
I (we) hereby authorize Fred Hamm Inc. hereinafter called COMPANY, to initiate debit entries to my (our) Checking Account indicated below at the depository financial institution named below, hereinafter called Bank Name. I (we) acknowledge that the origination of ACH entry transactions to my (our) account must comply with the provisions of U.S. law. If your billing pre fix is RES/COM Your Account will be debited on the 10th of each month. If your billing pre fix is JSH/JSC Your Account will be debited on the 25th of each month. Any billing questions need to be resolved before this date!
Bank Information
Bank Name: _________________________________________
Branch: ______________________________________________
Street Address: _________________________________________
City: ___________________State: ____________ Zip: ___________
Routing Number: ________________________________________
Account: Number: _________________________
This authorization is to remain in effect until Fred Hamm Inc. has received written notification from me (or either of us) of its termination and has been provided in a time and manner which affords Fred Hamm Inc. and DEPOSITORY a reasonable opportunity to take action.
Fred Hamm Account Information
Date:____________________
Name(s): ________________________
Phone Number: _______________________
Account Number:______________________________________
Signature(s): _______________________/___________________________