Fillable Printable Direct Deposit Authorization - Georgia

Direct Deposit Authorization - Georgia

Georgia Municipal Association

Finance Department

PO Box 105377

Atlanta, GA 30348

Direct Deposit Authorization

I authorize the Georgia Municipal Association to initiate electronic credit entries, and if necessary, debit

entries and adjustments for any credit entries made in error to my financial institution listed below:

Payee Name:

SSN:

E-mail:

Street Address:

City:

State: Zip:

Daytime Phone: Home Phone: Cell Phone:

Name of Financial Institution:

Financial Institution Phone Number

Account Type:

(Check One)

Checking

Savings

Address of Financial Institution:

City

State

Zip

TRANSIT

ROUTING

NUMBER

| ¦

CHECKING

ACCOUNT

NUMBER

Payee Signature

Date

SIGN Form & Do not forget to attach a VOIDED CHECK

Please do not use a voided deposit slip

(Fold on this line and insert in enclosed window envelope)

Make sure address appears in the window

PO Box 105377 • Atlanta, Georgia 30348 • 678/686-6297 • Fax: 678/686-6369

STAPLE VOIDED CHECK HERE