ACH AGREEMENT
PREARRANGED PAYMENT 
AUTHORIZATION AGREEMENT

AUTHORIZATION AGREEMENT FOR AUTOMATIC ACH DEBITS


Client Name: ___________________________________


I (we) hereby authorize Central Wyoming Rescue Mission, hereinafter called COMPANY, to initiate debit entries and to initiate, if necessary, credit entries and adjustments for any debit entries in error to my (our) (  )Regular Checking Account (  )Regular Savings Account (select one) indicated below at the depository named below, hereinafter called DEPOSITORY, to debit and/or credit the same to such account.



DEPOSITORY NAME _________________________________________________


CITY_______________________STATE____________________ZIP__________


TRANSIT/ABA NO.______________________ACCOUNT NO._________________

DATE OF DEBIT—17TH DAY OF EVERY MONTH.

For my benefit and convenience, Company is hereby authorized to debit my account for $_____________ that have been outlined to me by the Company in its ACH agreement. This authority 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 reasonable opportunity to act on it.

NAME(S)______________________________________________________________________________________________________________ 
            (Please print)


DATE ______________ 


SIGNED X ____________________________________________


SIGNED X ____________________________________________

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