Electronic Check Transfer Authorization

My ACH Company
Electronic Check Transfer Authorization Form

As a duly authorized signatory on the financial institution account identified below, I authorize My ACH Company (Company) to initiate electronic transfers and/or demand drafts, hereafter referred to as Automated Clearing House (ACH) transfers, to or from my bank account upon my request. I acknowledge that such requests, originated by myself and authorization validated via the use of my Account ID and Password over the Internet or telephone, constitute my authorization for such ACH transfers.

Furthermore, if any such ACH debits from my bank account are returned by my financial institution as Non-Sufficient Funds (NSF), an NSF fee of $30 USD for each NSF will be charged to my bank account and such debits may be re-billed to my bank account. To ensure collection of funds, this agreement and my provided information may be forwarded to my financial institution, or to a designated collection agency.

I acknowledge that payout requests cannot be processed until all funds are cleared and received for all deposits made into my Company account.

The Company, at its sole discretion, may request from me to submit additional information to verify my banking information or personal information as provided.

Please enter your information below.

Customer Account ID:
Full Name:
Bank Name:
Bank Routing Number:	(9 digits USA / 8 digits CDN)
Bank Account Number:

I hereby understand and authorize the above as evidenced by my signature below.

Signature: _________________________________________ Date: _____________________

Fax or email this signed and dated agreement along with:
EITHER

a legible copy of a signed VOIDED personalized check if using a Checking Account

or a legible copy of your Bank Statement detailing your name and account number if using a Savings Account.

AND

a legible photocopy of picture ID (e.g. Drivers License or Passport)

PLEASE FAX TO: n/a
- OR -
SCAN & EMAIL TO: support@whitesector.com

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