ACH Authorization – LM – Netsirv Production Site

AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (ACH)

Your Name

Company Name

EIN / SS ID

CANCELATION NOTICE: This authorization is to remain in full force and effect until the COMPANY named above has given written notification of its termination.

Depository Financial Institution

Depository Bank Name

Branch Name

Branch Address

City, State and Zipcode

Account Details

ABA / Routing Number

Account Number

Do you authorize Recurring Payments?

Transfer Autorization

I hereby authorize Local Motion, LLC, hereinafter called, to initiate debit and or Credit entries to the checking or savings account indicated in this form. The depository financial institution named, debit the same to such account. I acknowledge that the origination of ACH transactions to my account must comply with provisions of US law.

Signiture

Note: All written debit authorizations must provide that the debtor may revoke the authorization only by notifying the originator in the manner specified in the Authorization.

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