Fillable Printable Form FM-138 - Authorization Agreement for Direct Deposits - New York

Form FM-138 - Authorization Agreement for Direct Deposits - New York

AUTHORIZATION AGREEMENT FOR DIRECT DEPOSITS

(ACH DEBITS/ CREDITS)

Depository Name: _______________________________ Branch: ____________________________________

City: ______________________________________________ State: ________ Zip: __________ - _________

Routing Account

Number: ________________________________________ Number: __________________________________

This is a (please check one):

o Personal Account o Business Account

Signature:ç__________________________________

Title: ______________________________________

(please print)

Name:______________________________________

(please print)

ID number:__________________________________

(from driver’s license or ID card)

State of driver’s license or ID: __________________

Date (mm/dd/yyyy): __________________________

Signature:

ç__________________________________

Title: ______________________________________

(please print)

Name:______________________________________

(please print)

ID number:__________________________________

(from driver’s license or ID card)

State of driver’s license or ID: __________________

Date (mm/dd/yyyy): __________________________

I (we) hereby authorize New York State Department of Motor Vehicles to initiate Debit/Credit entries to my

(our) checking account indicated at the depository financial institution named below, hereafter called

Depository and to debit/credit the same to such account. I (we) acknowledge that the origination of ACH

transactions to my (our) account must comply with the provisions of United States law.

Should the Depository respond to an ACH with a notice of change, I (we) authorize the Department of Motor

Vehicles to update the account information, and to notify me (us) of the change.

The account information stored at the Department of Motor Vehicles for the purposes of processing an ACH

transaction may be modified by me (us), and this agreement remains in effect with the new account

information.

This Authorization is to remain in full force and effect until New York has received written notification from

me (either of us) of its termination in such time and in such manner as to afford New York State Department

of Motor Vehicles and Depository a reasonable opportunity to act on it. Written notification of termination

Company FINS Account

Name ___________________________________________ Number______________________________

FM-138 (7/15)

reset/clear