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Automatic Cash Transfer ACH Application Form

Name or Organization *
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Email *Ex. [email protected]
Phone *Ex. (XXX) XXX-XXXX

Banking Information

Name on Checking Account: *

Financial Institution: *

Example:

Choose either Checking OR Savings account. Enter account information below. *

I wish to have my payments withdrawn automatically from the following account:Checking AccountSavings Account

Customer's Account Number *

Bank Routing / Transit Number *

Legal Confirmation

I hereby authorize the financial institution I have named on this application to change the account I have specified for payment on my Redbank Valley Municipal Authority monthly invoice. I agree that such charge to my account shall be the same as if I had signed a check to pay my bill. I have the right to stop payment of a charge by notifying Redbank Valley Municipal Authority within 15 (fifteen) days of the due date of my bill. I may elect to discontinue my enrollment in this plan at any time.

Signature *Please type your full name

Date *Please enter today's date xx/xx/xxxx

Verification

Please enter any two digits *Example: 12
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