Authorization Agreement for Direct Deposit (ACH Debits)

AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS

ACH Debits • This information will be treated in a confidential manner.
Company Name: Sunrise Cooperative Inc

Company Identification Number: 34-1635886

I(we) hereby authorize Sunrise Cooperative, Inc hereinafter called company, to initiate debit entries to my(our) checking account indicated below at the depository financial institution named below, hereinafter called depository, and to debit the same to such account, or offsetting entries for the purpose of correction entries.
CHECKING ACCOUNT
Depository (Bank) Name:*
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
(to receive a copy for your records)
Routing Number:*
Account Number:*
Sunrise Customer Account Number:*
Name on Account:*

First NameLast Name
Signature:*

Clear
Date:*

MonthDayYear
Date
Additional Name on Account?

YesNo
Name on Account:

First NameLast Name
Signature:

Clear
Date:

MonthDayYear
Date
Please choose the account option you want Sunrise to ACH by selecting one of the following:*

Regular AccountBudget AccountRegular/Budget Account
All joint accounts must be signed and dated by both parties. A voided check must be uploaded to this form. Please take a photo of your voided check clearly showing the routing and account numbers. Your account balance will be drafted on the 25th of each month from your bank account.
Upload a photo of your voided check here:

Cancelof
ACH Withdrawl Options:

Budget Account: Automatic withdrawl of your budget amount only. Any amount due on your regular account is not withdrawn and must bepaid separately. Select this option if you do not want any balance due in May automatically withdrawn.

Regular/Budget Account: All eleven monthly budget payments will be automatically withdrawn. In addition, any amount due in May when we balance your account will also be automatically withdrawn. Select this option if you want any balance due on your regular and budget account automatically withdrawn.
Should be Empty:

AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS

CHECKING ACCOUNT