Bank Draft - Bloomingdale Utility District

Automatic Bank Draft

BLOOMINGDALE UTILITY DISTRICT
3212 BLOOMINGDALE RD.
KINGSPORT, TN 37660
(423) 288-6551

Acknowledgement

I hereby authorize Bloomingdale Utility District, hereinafter called Company, to initiate debit entries for the account indicated below and the financial institution named below, hereinafter called Financial Institution, to debit the same to such account. I acknowledge that the origination of ACH transactions from my account must comply with the provisions of the U.S. law.

Customer Service Adress

City/State

Zip

Financial Institution Name

Routing #

Account #

Acknowledgement

This authority is to remain in full force and effect until Company has received written notification from me of its termination in such time and manner as to afford Company and Financial Institution a reasonable opportunity to act on it.

Print Name

Signature

Accept Printed Name As Signature

Date

Phone Number

PLEASE ATTACH COPY OF VOIDED CHECK TO THIS FORM

Yes

Voided Check

Notes: All written debit authorizations must provide that the Receiver may revoke the
authorization only by notifying the Originator in the manner specified in the authorization.

Single-entry reversals do not require authorization by the Receiver. Therefore, previously
recommended language regarding the initiation of possible debit entries is no longer stated in
the authorization.

The underlined language above represents the disclosure requirements associated with the
clarification of OFAC economic sanction policies upon ACH Network Participants.

Automatic Bank Draft

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Hours

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