Direct Deposit Authorization Form - Fargo Care Solutions LLC

DIRECT DEPOSIT AUTHORIZATION

Name(Required)

First Middle Last

Social Security Number

Phone(Required)

Action

New

Change

Cancel

Effective Date

Name of Financial Institution

Account Number (Includes hyphen but not spaces and special symbols)

Type of Account

Checking

Saving

Routing Transit Number [Must be 9 characters)(The first two numbers was 01 through 12 or 21 to 32)

Type of Account

Solo

Joint

Other

By signing this agreement, I authorize the account indicated above for the purpose of expense and/or payroll transactions.

I also authorize the initiation of debit entries and adjustments, if necessary, to correct any credit entries made in error.

Signature

Date

If the account is a joint account or in someone else's name, that individual must also agree to the term stated above before signing below.

Signature

Date

HOW TO COMPLETE THIS FORM

1) Fill all the necessary data in the boxes above.

2) Sign and date the form.

TIPS:

1) Call your financial institution to make sure they accept direct debit.

2) Verify your account number and routing transit number with your financial institution.

3) Do not use a deposit slip to verify the routing number.