ACH Application Form | Connect12.io

ACH DIRECT DEPOSIT AUTHORIZATION FORM (MEMBERS)

MEMBER INFORMATION

Full Name *

Business Name(if applicale)

Your Email *

Phone Number

Address

State

Zip *

BANK ACCOUNT INFORMATION

Bank Name *

Bank Account Number: *

Bank Routing Number *

Account Type:

Checking

Savings

I hereby authorize LBW to initiate electronic Automated Clearing House (ACH) deposits to my bank account indicated above and, if necessary, initiate adjustments for any transactions made in error. This authority will remain in effect until LBW has received written notification from me of its termination in such time and in such manner as to afford LBW a reasonable opportunity to act on it.

Member Signature: By signing below, I confirm that I am the authorized account holder and have read and agreed to the terms of this ACH Direct Deposit Authorization Form.

PLEASE NOTE

This form must be completed accurately and signed by the Member.
Attach a voided check from the bank account listed above to verify routing and account numbers.
Return the completed form and voided check to LBW for processing.

Important Note: The submitted bank account information will be used for direct deposit payments to Members. Please ensure the accuracy of the information provided. LBW will keep your information confidential and use it solely for the purpose of processing direct deposit payments.