form test

DTMA Authorization Agreement for Direct Payment (ACH Debits)

APPLICANT
DTMA Account Number*
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Daytime Phone*
Cell Phone*
Email*
I hereby authorize Doylestown Township Municipal Authority to initiate debit entries and to initiate, if necessary, credit entries and adjustments for any debit entries in error to my bank account indicated below and the financial institution named below, to debit and/or credit the same to such account. I understand there shall be a $35.00 charge for any insufficient fund transactions.
BANK INFORMATION
Account Type*
- Checking Account
- Savings Account
Financial Institution*
Branch*
Address*
City State / Province / Region ZIP / Postal Code
Transit / ABA No.*
Account Number*
This authority is to remain in full force and effect until Doylestown Township Municipal Authority has received written notification from me of its termination in such time and in such manner as to afford Doylestown Township Municipal Authority and the financial institution named above a reasonable opportunity to act on it.
Customer Signature*
First Last
Date*
Date Format: MM slash DD slash YYYY
*A blank void check must accompany this application. Deposit slips cannot be accepted. All fields must be filled in. Incomplete forms will not be accepted.

APPLICANT