ACH Form

Payor information

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1. Name:

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2. Phone number:

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3. Billing address:

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4. Email address:

Payee information

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5. Name:

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6. Phone number:

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7. Billing address:

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8. Email address:

Transaction information

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9. Is this transaction:

Personal

Business

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10. Account type:

Savings

Checking

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11. Transaction amount:

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12. Transaction date:

Date / Time

Date

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13. Signature:

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14. I acknowledge that by entering my name above I am providing a digital signature.

Yes

No

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