Service Manual
Forms
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10 T Asset Acquisition Company, LLC
Page 66
Authorization Agreement for Automated Payments
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financial institution named below, hereinafter called DEPOSITORY and to debit the same such account. To
correct errors, I (we) authorize Play
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DEPOSITORY and to credit the same account. I (we) acknowledge that the origination of ACH transactions to my
(our) account must comply with the provisions of U.S. law. I (we) attach an unsigned and void check for a
checking account for my (our) account indicated below. For savings account, I (we) attach document on bank
letterhead containing Bank Routing Number and my (our) Account Number or a bank deposit slip for my (our)
savings account.
Company Name
Checking Account
Savings Account
Address Bank
Account
Number
City, State, Zip
ABA Bank routing number
Company Contact
Bank Name
Phone Number
( )
Fax number
( )
Bank Address
Email Address
City, State, Zip
Distributor
Bank Phone Number ( )
NOTICE.
To assist in verifying data, attach an unsigned, void, blank check or deposit slip from your account.
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me (us) of it
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reasonable opportunity to act on it.
NOTE:
All written debit authorizations
MUST
provide that the receiver may revoke the authorization only by
notifying the originator in the manner specified in the authorization.
Authorized Signature
(Signature must accompany this form.)
Title
Date
Mail or fax completed form to
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800 Roosevelt Road, Suite D-103, Glen Ellyn, IL 60137
Phone (630) 942-1070
Fax (630) 942-1073
Fax (630) 348-2099
For processing, allow 6 to 10 business days.
Rev. 4
