AUTHORIZATION AGREEMENT FOR AUTOMATIC DEPOSITS (ACH CREDITS)

I hereby authorize Belleville Township High School District No. 201, hereafter known as “the DISTRICT”, to initiate credit entries and, if necessary, debit entries and adjustments for any credit entries in error to my checking/savings account with the depository named below, hereafter called “DEPOSITORY”, to credit and/or debit the same to such account.

DEPOSITORY NAME:

BRANCH LOCATION:

*** PLEASE ATTACH A VOIDED CHECK FROM THE ABOVE ACCOUNT. ***

ROUTING #	ACCOUNT #

I understand that although there is no cost to me associated with beginning direct deposit, any changes in my account number or financial institution may result in a charge against my account levied by the DEPOSITORY.

This authority is to remain in full force and effect until the DISTRICT has received written notification from me of its termination, in such time and in such manner as to afford the DISTRICT and the DEPOSITORY a reasonable opportunity to act on it.

NAME (Please print):

EMAIL ADDRESS (for direct deposit slips):

SIGNATURE:	DATE: