16965 Pine Lane, Suite 200 Parker, CO 80134 | T: 855.873.5873 | F: 866.411.8258 | thesolomonfoundation.org
ELECTRONIC FUNDS TRANSFER / BANK ACCOUNT AUTHORIZATION
Owner _____________________________________________________________________________________________________
Co-Owner (if applicable) _________________________________________________________________________________________
Mailing Address _____________________________________ City ______________________ State _________ Zip ___________
Phone: #1 _____________________ #2 _____________________ E-Mail ___________________________________________
I hereby authorize The Solomon Foundaon to iniate debit or credit entries at my direcon and to iniate, if necessary, credit or debit entries and adjustments for
any debit or credit entries in error to my account indicated below and the depository bank named below to debit or credit the same to such account. I understand
that The Solomon Foundaon may contact me to verbally verify the informaon listed below and may not accept this form if vericaon cannot be made.
Bank Name _________________________________________________________________________________________________
Bank Address _______________________________________ City ______________________ State _________ Zip ___________
Name on Bank Account _______________________________________________________________________________________
Bank Roung Number (ABA) ________________________________ Bank Account Number ______________________________
Account Type ❑ Checking Account ❑ Savings Account*
*(If draing from a savings account, please include a leer from your bank conrming that they allow ACH transacons as well as the account & roung numbers.)
Note: A return check fee of $25 will be charged for insucient funds.
I hereby authorize The Solomon Foundaon to iniate debit entries and to iniate, if necessary, credit entries and adjustments for any debit entries in error to my
account at the bank named above. I authorize the bank to accept any such debits or credits to my account without responsibility for their correctness. I further
agree that The Solomon Foundaon will not incur any loss, liability, cost, or expense for acng upon this request. I understand that this authorizaon may be
terminated by me at any me by wrien nocaon to The Solomon Foundaon and to the bank. The terminaon request will be eecve upon thirty (30) days
wrien noce.
Print Name ______________________________________ Print Name __________________________________________
Signature ________________________________________ Signature ____________________________________________
Date ___________________________________________ Date _______________________________________________
*Two signatures are required for those investments opened with a two signature requirement.
1. INVESTOR INFORMATION
2. AUTHORIZATION
3. ACKNOWLEDGMENT
