Fillable ACH Form Direct Payment Authorization (ACH) (University of Delaware)

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ACH Form Direct Payment Authorization (ACH) (University of Delaware)

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The ACH Form Direct Payment Authorization (ACH) (University of Delaware) form is 1 page long and contains:

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Office of Human Resources
413 Academy Street
Newark, DE 19716
302-831-2171
DIRECT PAYMENT AUTHORIZATION
By completing and returning this form, you will establish an easy and less costly
way of paying your benefit premiums to the University of Delaware. This
authorization to debit your account will remain in effect until we receive written
notification from you of its termination, and the University of Delaware has had
reasonable opportunity to process your change. This debit will be recorded on
your monthly bank statement. Please anticipate the first debit of funds from your
account within 30-40 days after your return of this form. The University will
provide you with at least 30 days notice of any increase in the amount of your
benefit premium(s).
AUTHORIZATION AGREEMENT
I (We) hereby authorize the University to initiate debit entries to my (our)
checking account indicated below at the depository financial institution named
below, hereinafter called depository, to debit the same to such account.
Depository:
Branch:
City:
State:
Zip:
Routing #:
Account:
Amount to Debit (on or about the 10
th
of each month)
This authorization is to remain in effect until the University of Delaware has
received written notification from me (or either party of a joint account signing
below) of its termination in such time and such manner as to afford the University
of Delaware and the Depository a reasonable opportunity to act on it.
Name:
Please Print
Signature:
Name:
Please Print
Signature:
PLEASE NOTE:
A voided check must accompany this form.
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ACH Form Direct Payment Authorization (ACH) (University of Delaware)

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Completed 24 July 2020

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