To: ______________________________
Clearing Agent – Wedbush Securities Inc.
I.E. Code Securities Account Number
Automated Clearing House (ACH) Authorization
Securities Account Information
Name: Social Security/Tax I.D. Number:
Bank Account Information
Name as it appears on your Bank Account:
Bank Account Num
b
er:
Bank Account Type (select one): Savings Checking
Type of Transfer
I/we elect to make transfers on-demand between my/our securities account and bank account as follows*:
1. From: Bank Account (specified above) To: Securities Account (specified above)
Amount: $________________ Beginning Date: / /
Month Day Year
Recurring: Monthly Quarterly Semi-Annually Annually
2. From: Securities Account (specified above) To: Bank Account (specified above)
Fixed Amount: $________________* As requested only* Dividends & Interest *
Beginning Date:
/ /
Month Day Year
Recurring: Monthly Quarterly Semi-Annually Annually
*
Important Note for IRA Accounts: If you are using this form to withdraw funds from an IRA account in which Wedb
ush
Securities Inc.
is the custodian, you must attach Form ID to set up a Fixed Amount or Dividend & Interest distribution and/or Form
IA to set up As requested only distributions.
Please Read and Sign
I/we authorize you and your clearing agent to transfer funds between my/our securities account and my/our bank account
via ACH funds transfer. In the event an entry is incorrect, I authorize you and/or your clearing agent, at your discretion,
the right to submit correcting entries. Attached is a voided check so that you have my/our necessary bank routing
information. I/we authorize my/our “Bank Account Information” to be released to you and/or your clearing agent for
verification purposes. I/we will confirm activation of these ACH instructions before making financial commitments based
upon these instructions. This authorization remains in full force and effect until you and your clearing agent receive
written notification of its termination or amendment. I/we acknowledge that ACH transactions to or from my/our account
must comply with the provisions of U.S. Law, Internal Revenue Code and National Automated Clearing House
Association Rules.
X _____________________________________ _________ X
_____________________________ __________
Applicant’s Signature Date Joint Applicant’s Signature Date
0507CSD ACH
Attach Voided Check Here
CONNIE SILVERS 2032
12345 Any Street, Apt. 123
Somewhere, CA 90205
PAY TO THE
ORDER OF ______________________________________________________
_
____________________________________________________________________________________
_
DOLLARS
322271627 8769982336 0029900 2032 __________________________________________
For Office Use Only:
X _____________________________________ _________
Signature Guaranteed by Authorized Signatory Date
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