AUTHORIZATION AGREEMENT
FOR ACH
DEBIT
_________________________________________________________________________
______________
This iiX transaction will reference ISO Claims Services Inc. on your bank statement.
_____________________________________________________________________________
(As It
Appears
On Bank
Account
)
Name
Of Ba
nk:
________________________________________________________________
Bank (ABA)
Numb
e
r:
_________________________________________________________
Bank Account
Numbe
r:
_________________________________________________________
I agree that
this authorization
will remain in effect until I provide
written notification
terminating this service.
(ACH transaction will occur on 15
th
following invoice date or next business day). of
invoice date
or next business
day).
OR
One time only authorization as described below:
INVOICE NUMBER INVOICE AMOUNT
Total ACH Debit Amount:
_________________________________________________________________
Approval (Authorized signature
for bank
account)
________________________________________________________________________
• For rec
urring monthly ACH debit
authori
z
ations
,
please submit completed
form
AND voided check to Accounts
Receivable
,
fax number (201)
748-1348.
• For one-time
authorizati
o
n
s
,
please submit completed forms to
Acco
unt
s
Receivable, fax number
(201) 748-1348.
