CHECKING/SAVINGS AUTHORIZATION FORM
I (we) hereby authorize GPS Insight, LLC to iniate deposits to my (our) checking/savings accounts at the nancial
instuon listed below, and, if necessary, iniate adjustments for any transacons credited/debited in error. This
authority will remain in eect unl GPS Insight, LLC is noed by me (us) in wring to cancel it in such me as to
aord GPS Insight, LLC a reasonable opportunity to act on it.
Name of Financial Instuon: 
Address of Financial Instuon: 
Company Name: 
Address: 
Financial Instuon Roung Number: 
Checking/Savings Account Number: 
(Branch, City, State & Zip) 
Payment Remiance Email 
Signature 
GPS Insight, LLC | 866-477-4321
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