ACTION-Housing, Inc.
Emergency Rental Assistance Program
Authorization Agreement for Automatic Entries
Date:
Organization/Individual Name:
I hereby authorized ACTION-Housing, Inc. to initiate credit and/or debit entries and, if necessary, any
adjustments needed to correct entries made in error, to account(s) indicated below, and the nancial
institution named below, to credit and/or debit the same to such account(s). I acknowledge that
the origination of ACH transactions to my account must comply with the provisions of U.S. Laws and
Regulations including the Sanction Laws administered by the Oce of Foreign Asset Control.
Please attach a voided check to this form and return it to ACTION-Housing, Inc.
Financial Institution Name:
City: State: Zip Code:
Transit / ABA Number (Nine-Digit Code):
Account Number:
Account Type: Checking Savings
This authorization is to remain in full force and eect until ACTION-Housing, Inc., has received
written notication from the organization of its termination in such time and such manner as to aord
ACTION-Housing, Inc. a reasonable opportunity to act on it.
Approved by: Print Name
Title:
Email Address: Phone:
Signature:
Date:
Revised 3/7/2021
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