ACH Authorization Agreement

Utility Billing Solutions, LLC

ACH Authorization Agreements

Company Name: Utility Billing Solutions, LLC

Company ID Number: 3458

I (we) hereby authorize __Utility Billing Solutions, LLC hereinafter called COMPANY, to initiate debit entries to my (our) Checking Account/Savings Account indicated below at the depository financial institution named below, hereinafter called DEPOSITORY, and to debit the same to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law.

Bank Account Information

Depository Branch *

Please Select One *

Checking AccountSavings Account

Your Name *

Your Email *

City *

State *

Zip *

Routing Number *

Account Number *

This authorization is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a 30 day opportunity to act on it.

Names *

Phone Number *

Date (mm/dd/yyyy) *

Signature (use your mouse to write your signature and sign this application) *

NOTE: ALL WRITTEN DEBIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR 30 DAYS PRIOR TO THE CANCELLATION DATE.

Utility Billing Solutions Account Information

Utility Billing Solutions Service Address *

Name On The Account *

Utility Billing Solutions 6 Or 7 Digit Account Number *

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