®
Auto Deduct Authorization Citibank EZ Funding Form
CLIENT INFORMATION
New Client
Existing Client
Existing Client Acccount Number:
Client Name
U.S. BANK ACCOUNT INFORMATION
Include in this section the information related to your account with your other Financial Institution in the USA.
Financial Institution Name
Account Name(s)
Bank Routing Number
Bank Account Number
Account Type - Check One
Checking
Money Market
Savings
Please include support documentation corresponding to the account
to be auto-deducted for verification purposes. For more information
regarding support documentation, please review instructions on the
following page.
Amount to be transferred (USD)
US$_____________________________________________________________________
Customer Authorization
I authorize Citibank, N.A., to withdraw from my U.S. account at the financial institution named in this application for funding of my Citibank
checking account. This authorization will remain valid for a period of thirty (30) calendar days from the date I have included below
or until Citibank, my financial institution, or I revoke it, whichever occurs first. I understand and agree that Citibank and/or my financial
institution reserves the right to revoke this instruction at any time and Citibank and/or my financial institution shall not be liable
for any damages or consequences resulting from such revocation. I understand that if I want to revoke this authorization I have to
call CitiPhone Banking® at 1 (813) 604 3000.
Signature
Date
International Personal Banking and Citigold International are United States businesses that provide its clients access to a broad array of products and services
available through various bank and non-bank affiliates of Citigroup. Banking products and services are provided by Citibank, N.A., member FDIC. Products and
services offered by Citi and its affiliates are subject to the applicable local laws and regulations of the jurisdiction where they are booked and offered. Not all
accounts, products, and services as well as pricing are available in all jurisdictions or to all customers. Your country of citizenship, domicile, or residence may
have laws, rules, and regulations that govern or affect your application for and use of our accounts, products, and services, including laws and regulations
regarding taxes, exchange and/or capital controls.
FOR BANK INTERNAL USE ONLY
New Citibank Account Number (Only for New Clients)
Name of Citibank Officer / Citibank Affiliate Officer receiving* the form
Signature
Date
*Acceptance and processing of this form will be executed in Tampa Distribution Unit - Citibank, N.A. in the United States.
©2010 Citibank, N.A. member FDIC.
Citibank with Arc Design is a service mark of Citigroup, Inc. or Citibank, N.A., used and registered throughout the world.
IPBCIEZ0710
FOR
D
I
VO
Instructions for the Auto Deduct Authorization Citibank EZ Funding Form
Below is an illustration of how to locate the Routing Number and Account Number on your check.
0301
Joe Sample
1 Main Street
Home Town, State 12345
DATE
$
YOUR FINANCIAL INSTITUTION
FOR
Your Routing Number: to locate
your routing number, simply look at
the bottom left-hand corner of your
checks. The first set of numbers
listed is your routing number.
Your Account Number: to locate
your account number, look at the
bottom of your checks, to the right
of the routing number. In some
instances, your account number
may be listed immediately after
your routing number, or it may
appear after the check number.
Supporting Documents
The supporting documentation is required for verification purposes. Below are the three types of documents that Citibank will accept to serve
as supporting documentation. Please note that you only need to provide ONE of the following supporting documentations:
1) Account Statement:
Must not be older than 3 months and must be addressed to the title holder who signs the Auto Deduct Authorization Citibank EZ Funding Form
who should also be a title holder on the Citibank, N.A. account to be credited. The statement must also include full account number which must
match the account number in the Auto Deduct Authorization Citibank EZ Funding Form.
or
2) Bank Reference Letter:
Must include full name of the title holder that signs the Auto Deduct Authorization Citibank EZ Funding Form, who must also be one of the title
holders on the Citibank, N.A., account to be credited and the full account number which must match the account number in the Auto Deduct
Authorization Citibank EZ Funding Form;
or
3) Void Check (Not available for Ecuadorian clients):
Must have title holder names printed on the check. The signer of the EZ Funding Form should be one of the title holders on both the account to
be debited and the Citibank, N.A. account to be credited. ABA number and account number on the check should match ABA number and account
number on the EZ Funding Form;
Joe Sample
1 Main Street
Home Town, State 12345
D
I
O
V
0301
DATE
$
YOUR FINANCIAL INSTITUTION
FOR
Joe Sample
1 Main Street
Home Town, State 12345
If you need to void a check, write “VOID” in large
letters across the check as shown above.
YOUR FINANCIAL INSTITUTION
FOR
©2010 Citibank, N.A. member FDIC.
Citibank with Arc Design is a service mark of Citigroup, Inc. or Citibank, N.A., used and registered throughout the world.