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ACH Authorization for Notary Services

This document is an authorization form allowing Berkshire Notary Services to initiate automatic payments from a customer's checking or savings account. The customer provides their financial institution information and signatures to permit Berkshire Notary Services to debit set amounts or maximum amounts directly from the designated bank account. The authorization will remain in effect until the customer cancels it in writing.

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Thomas Keeler
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180 views1 page

ACH Authorization for Notary Services

This document is an authorization form allowing Berkshire Notary Services to initiate automatic payments from a customer's checking or savings account. The customer provides their financial institution information and signatures to permit Berkshire Notary Services to debit set amounts or maximum amounts directly from the designated bank account. The authorization will remain in effect until the customer cancels it in writing.

Uploaded by

Thomas Keeler
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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From the Office of 370 Fort Hill Avenue

Thomas A. Keeler Pittsfield, MA 01201


Berkshire Notary Services (413) 358.5104

ACH Authorization Form

I (we) hereby authorize Berkshire Notary Services (the company) to initiate entries to my (our)
checking/savings accounts at the financial institution listed below (the Financial Institution), and, if
necessary, initiate adjustments for any transactions credited/debited in error. This authority will remain
in effect until Berkshire Notary Services is notified by me (us) in writing to cancel it in such time as to
afford Berkshire Notary Services and the financial institution a reasonable opportunity to act on it.

______________________________________________

(Name of Financial Institution)

______________________________________________

(Address of Financial Institution)

_________________________________ ________/________/________

(Signature) (Date)

_________________________________

(Name – Please Print)

______________________________________________

(Address – Please Print)

Set amount $________ or Maximum Amount $________

Financial Institution Routing Number: ________________________________

Checking/Savings Account Number: ______________________________

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