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CHECKING
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SAVINGS
ACH/EFT AUTHORIZATION FORM
For Receiving Payment by Electronic Funds Transfer (EFT)
PLEASE COMPLETE THIS FORM AND RETURN TO:
201 E. Oak Street, Suite 205
Arcadia, FL 34266
PART 2: Pay - Identification
4. Utility Account Number
5. City
6. State
7. Zip
PART 3: Authorization for Setup, Changes, or Cancellation
I hereby request and authorize the County of DeSoto to withdraw payments on the 5
th
day of the month or around the first week of the month
by electronic funds transfer out of the account specified below and if necessary, debit entries and adjustments for any amounts withdrawn
electronically in error. I recognize that if I fail to provide complete and
accurate information on this authorization form, the processing of the
form may be delayed or my payments may be erroneously transferred electronically.
This authorization will remain in effect until written notice to terminate is given. The undersigned must allow 4 - 6 weeks for initiating or
terminating Electronic Funds Transfer and is responsible for notification of any change in financial institution information.
PART 4: Financial Institution
12. Financial Institution Name
16. Routing Transit Number
The Customer Name, Bank Routing Number, and Customer Bank Account Number on the
attached voided check
must match
the information provided in Part 4. If any discrepancies are
identified, the ACH setup will be terminated and the customer will need to reapply.
PART 5: Attach a VOIDED check here
1. Fill in all fields (1 - 18) legibly and completely. (Keep a copy for your own records)
2. Attach a voided check to front of form. Make sure that the account number and bank routing numbers at the bottom of the
check are the same ones you indicated in items 16 - 17.
3. Send the Form to address indicated at top of form.
3. You must notify the Finance Department immediately of any changes to your account information.
4. Once the set-up has been activated, your payments will be withdrawn via ACH permanently, unless you fill out a new form and indicate that you
are cancelling the service.
17. Bank Account Number
