CITY OF SOCIAL CIRCLE
DIRECT PAYMENTS
I (We) herby authorize City of Social Circle, hereinafter called COMPANY, to initiate debit entries to my (our)
Checking Account
Savings Account
indicated below at the depository financial institution named below, hereinafter called Pinnacle Bank, and to
debit the same to such account. I (We) acknowledge that the origination of the ACH transactions to my (our)
account must comply with the provisions of U.S. law.
AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (ACH DEBITS)
Customer Name:
Customer ID Number:
Bank Name: Branch:
City: State:
ZIP:
Routing Number:
Account Number:
This authorization is to remain in full force and effect until City of Social Circle has received written notification
from me (or either of us) of its termination in such time and in such manner as to afford the City of Social
Circle and Pinnacle Bank a reasonable opportunity to act on it.
Property Address:
Name(s):
Phone Number:
ID Number:
Signature: Date:
City of Social Circle Representative:
NOTE: ALL WRITTEN DEBIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE
AUTHORIZATION ONLY BY NOTIFYING THE ORGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION.
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