Authorization Agreement For Direct Deposits (ACH Debits-Credits) {FM-138}

AUTHORIZATION AGREEMENT FOR DIRECT DEPOSITS (ACH DEBITS/ CREDITS) Company FINS Account Name ___________________________________________ Number______________________________ I (we) hereby authorize New York State Department of Motor Vehicles to initiate Debit/Credit entries to my (our) checking account indicated at the depository financial institution named below, hereafter called Depository and to debit/credit the same to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of United States law. Should the Depository respond to an ACH with a notice of change, I (we) authorize the Department of Motor Vehicles to update the account information, and to notify me (us) of the change. Depository Name: _______________________________ Branch: ____________________________________ City: ______________________________________________ State: ________ Zip: __________ - _________ Routing Account Number: ________________________________________ Number: __________________________________ This is a (please check one): Personal Account Business Account The account information stored at the Department of Motor Vehicles for the purposes of processing an ACH transaction may be modified by me (us), and this agreement remains in effect with the new account information. This Authorization is to remain in full force and effect until New York has received written notification from me (either of us) of its termination in such time and in such manner as to afford New York State Department of Motor Vehicles and Depository a reasonable opportunity to act on it. Written notification of termination Signature:± __________________________________ Title: ______________________________________ (please print) Name:______________________________________ (please print) ID number:__________________________________ (from driver's license or ID card) State of driver's license or ID: __________________ Date (mm/dd/yyyy): __________________________ Signature:± __________________________________ Title: ______________________________________ (please print) Name:______________________________________ (please print) ID number: __________________________________ (from driver's license or ID card) State of driver's license or ID: __________________ Date (mm/dd/yyyy): __________________________ FM-138 (7/15) American LegalNet, Inc. www.FormsWorkFlow.com