Copyright © 2014 Lakeland Bank. All rights reserved. This material is proprietary to and published by Lakeland Bank for the sole
benefit of its clients. Reproduction, distribution, disclosure and use are expressly prohibited, except as authorized by license, or with
the explicit written approval of Lakeland Bank. The information contained herein is subject to change without notice. In no event will
Lakeland Bank be responsible for any direct, indirect, special or consequential damages resulting from the use of this information.
No warranties, either expressed or implied, are granted or extended by this document. Great care should be taken to ensure that
any use of this information complies at all times with all applicable laws, rules and regulations. Revisions may be issued to advise of
such changes and/or additions.
Copyright © 2014 Lakeland Bank, Revised 10/7/2014
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Copyright © 2014 Lakeland Bank, Revised 10/7/2014
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AUTHORIZATION AGREEMENT FOR DIRECT DEPOSITS (ACH CREDITS)
Company Name
I (we) hereby authorize
, hereinafter called COMPANY, to initiate
credit entries to my (our) □ Checking Account/ □ Savings Account (select one) indicate below at the depository
financial institution named below, hereafter called DEPOSITORY, and to 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 U.S.
law.
Depository
Name
Branch
City
State
Routing
Number
Account
Number
Zip
This authorization is to remain in full force and effect until COMPANY has received notification from me (or
either of us) of its termination in such times and in such manner as to afford COMPANY and DEPOSITORY a
reasonable opportunity to act on it. The undersigned Receiver agrees to be bound by the NACHA Operating Rules,
as amended and in effect from time to time.
Name(s)
Address
(Please Print)
Signature
Date
NOTE: WRITTEN CREDIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY
REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER
SPECIFIED IN THE AUTHORIZATION.
Copyright © 2014 Lakeland Bank, Revised 10/7/2014
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AUTHORIZATION AGREEMENT FOR PAYMENTS (ACH DEBITS)
Company Name
I (we) hereby authorize
, hereinafter called COMPANY, to initiate
debit entries to my (our) □ Checking Account/ □ Savings Account (select one) indicate below at the depository
financial institution named below, hereafter called DEPOSITORY, and to debit the same to such account. I (we)
acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S.
law.
Depository
Name
Branch
City
Routing
Number
State
Account
Number
Zip
This authorization is to remain in full force and effect until COMPANY has received notification from me (or
either of us) of its termination in such times and in such manner as to afford COMPANY and DEPOSITORY a
reasonable opportunity to act on it. The undersigned Debtor agrees to be bound by the NACHA Operation Rules,
as amended and in effect from time to time.
Names(s)
Address
(Please Print)
Signature
Date
NOTE: WRITTEN DEBIT AUTHORIZATIONS MUST PROVIDE THAT THE DEBTOR MAY
REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER
SPECIFIED IN THE AUTHORIZATION.
Copyright © 2014 Lakeland Bank, Revised 10/7/2014
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ACH Originator Guide