June 2018 v1
Mississippi Home Corporation
ACH CREDIT AUTHORIZATION FORM
As a payment option,
Mississippi Home Corporation
offers payees the opportunity to receive future payments electronically, rather
than by check. In addition to having the money deposited electronically, you will also be notified of the deposit by e-mail. If you
would like to receive electronic payments, please complete the following form.
Payee Information
Transaction Type:
Add
Change
Delete
Payee Phone
Number:
Payee Name:
SSN
or
Federal ID #:
Payee Physical
Address:
Financial Institution Information
Financial Institution Name:
City,
State:
9 Digit Routing Transit # for
ACH deposits:
Name on Account:
Account #:
Account
Type:
Checkin
Savings
E-MAIL
ADDRESS for payment notification.
Whereby we authorize Mississippi Home Corporation to initiate credit entries and to initiate, if necessary, debit entries and adjustments
for any credit entries in error to our account in the financial institution identified. We additionally authorize the financial institution to credit
and/or debit the same to our account.
This authority is to remain in effect until revoked by us in writing to Mississippi Home Corporation.
_____________________________
Title
_____________________________
Date
__________________________________________________________
Authorized Sign ature
__________________________________________________________
Printed Name
