ACH Recurring Payment Authorization Form
Central Valley Ag (CVA) now offers customers the option of paying their account balance via electronic funds transfer
from their checking or savings account. If you choose this payment option, you will continue to receive your monthly
statement on approximately the 2
nd
of the month, and the electronic transfer from your bank account will take place
on the 20
th
of the month.
Please complete the information below:
I ____________________________ authorize Central Valley Ag Cooperative to charge my bank
(full name)
account indicated below on the 20
th
day of the month for payment of my statement balance.
*If you desire to have the bank notify you on the date your account is debited
Account Type: Checking Savings
Name on Acct _______________________________
Bank Name _______________________________
Account Number _______________________________
Bank Routing # _______________________________
Bank City/State _______________________________
SIGNATURE DATE
I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Central Valley Ag in writing of
any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above
noted periodic payment dates fall on a weekend or holiday, I understand that the payment may be executed on the next business
day. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the
above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I
understand that Central Valley Ag may at its discretion attempt to process the charge again within 30 days, and agree to an
additional $30.00 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized
recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S.
law. I agree not to dispute this recurring billing with my bank so long as the transactions correspond to the terms indicated in this
authorization form.
Please return completed form to Central Valley Ag, PO Box 429, York, NE 68467-0429
or drop off at any Central Valley Ag location.
