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| Client ID: | _________________________________ |
| Client Name: | _________________________________ |
| Address Line 1: | _________________________________ |
| Address Line 2: | _________________________________ |
| City/State/Zip | _________________________________ |
| Checking or Savings Account: | Checking or Savings (circle one) |
| Name exactly as it appears on your Bank Account: | _________________________________ |
| Check Number to be used for this transaction: (You must void this check. Recurring transactions require only one check number) |
_________________________________ |
| Routing Number: (Routing number is the 1st set of numbers on the bottom left of your check) |
_________________________________ |
| Account Number: | _________________________________ |
| ACH Payment Date: | _______________(Month and date) |
| Would you like to authorize recurring payments on this date every month? |
No/Yes (circle one) |
| Amount of your payment: | $___________ + $12.00 = $ __________ |
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I authorize Federated Financial Inc., its agents, subcontractors, and affiliates and/or Western Union Commercial Services, to process debit entries from my account. This authority will remain in effect unless and until I, (Name of Account Holder) ____________________, revoke or amend it by notifying Federated Financial Inc. in writing not less than four (4) business days in advance of the transaction to be cancelled or changed. FEDERATED FINANCIAL reserves the right to refuse to process any ACH transaction without prior notice to the Client. I understand there will be a $29 fee automatically charged to my account for any insufficient funds (NSF) transactions. There is a $12.00 administrative fee added per transaction. If you have any questions or problems, please call (800) 533-4485. |
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| Name:__________________________ | Signature:__________________________ | Date:___________ |
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