Form – ACH Debit Form – Village of Hanna City, IL

PLEASE ATTACH COPY OF VOIDED CHECK TO THIS FORM! I (we) hereby authorize hereinafter called COMPANY, to initiate debit entries to my (our) account indicated below and the financial institution named below, hereinafter called FINANCIAL INSTITUTION, 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 US. law.
Company Name
Financial Institution Name & Branch
Address
Routing Number
Account Number
Type of Account*
- Checking
- Savings
First Verify ACH Debits are allowed out of your savings: if you choose savings from your Financial Institution
Your Name*
Phone Number*
Attach a copy of your voided check*
Max. file size: 500 MB.
This notification is to allow Village of Hanna City to Debit my Account on the 20th of each month. If the 20th falls on a WEEKEND or HOLIDAY deduction will fall on the NEXT BUSINESS DAY. This authority is to remain in full force and effect until Village of Hanna City has received written notification from me (or either of us) of its termination in such time and manner as to afford the Village of Hanna City and Hanna City Community Bank a reasonable opportunity to act on it.

The Village of Hanna City