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EFT Template
Please use this Template for EFT or Electronic Funds Transfer when authorizing a company to take a direct debit from the company bank account. You must attach a voided check to this form and only originals will be accepted they will not allow faxed copies.

Free Sample Template
Format: Word PDF
# of Pages: 1
Printable: Yes

EFT Template TemplateForm 1219
Format: Word PDF
Category: Business, Cashier
Type: Form
Electronic Funds Transfer Form

I hereby authorize the following company:

Company Name: _______________________________________________________________________________

Address: ______________________________________________________________________________________

City: _______________________________________ State: ____________ Zip Code:________________________

To initiate debit entries from my checking account from the financial institution listed below. If any of the information listed below changes I will immediately complete a new authorization agreement within fifteen business days.

Account Information:

Financial Institution Name: _______________________________________________________________________

Address: ______________________________________________________________________________________

City: _______________________________________ State: ____________ Zip Code: ________________________

I authorize the above listed company to withdrawal:

___ Reoccurring Flat Amount of $_________________ Or ___ ___________________________________________

___ Monthly ___ Weekly ___ Other ________________________________________________________

# ABA Bank Routing Number AND # Account Number


Please enter the above information from the bottom of you check without the check number. Also, please attach a voided copy of your check. Deposit slips are not accepted. Void the check. This authority is to remain in effect until the above listed company has received written notification from me with thirty days of its termination in such time to afford the company a reasonable opportunity to act upon the cancellation.

Signature of Officer: ___________________________________________________________ Date: ___/___/_____

Print Name: _____________________________________________________Title: __________________________

This original document shall remain on file and no copies will be accepted. All faxed copies shall be denied.