Fillable A Schedule ACH Authorization Agreement

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A Schedule ACH Authorization Agreement

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The A Schedule ACH Authorization Agreement form is 2 pages long and contains:

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Authorization Agreement
I (we) hereby authorize ConsumerDirect® dba SmartCredit® to initiate entries to my (our) account at
the
financial institution listed below. I (we) also authorize ConsumerDirect® dba SmartCredit® to make
adjustments for any transactions credited/debited in error.
This agreement will remain in effect until ConsumerDirect® dba SmartCredit® receives a written notice
of cancellation from me (us) to cancel it in such a time as to afford ConsumerDirect® dba SmartCredit®
and the financial institution a reasonable opportunity to act on it.
Account Information
Account Name:
Account Address:
Name of Financial Institution:
Routing Number:
Account Number:
☐ Checking Savings
Signature
Authorized Signature (Primary): Date:
Authorized Signature (Joint): Date:
Schedule
A
ACH Authorization Agreement
Schedule A & B (revised 01/2021)
Page 1 of 2
Schedule B
Credit Card transfer form for ConsumerDirect
®
Fees from Partner
Name on Credit Card: _______________________________________________
Credit Card Number: _______________________________________________
Expiration Date: _____ / _____
Security Code: ____________
Billing Address: _______________________________________________
_______________________________________________
Card Holder Signature: ________________________________
Date: ________________________________
Schedule A & B (revised 01/2021)
Page 2 of 2
Card Holder agrees to the terms and conditions of this Agreement.
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A Schedule ACH Authorization Agreement

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Completed 19 March 2021

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