Authorization For Direct Payment
VILLAGE OF ONTONAGON315 Quartz StreetOntonagon, Michigan 49953 Phone: 906-884-2305 Fax: 906-884-4369 TDD: 1-800-649-3777 Website: www.villageofontonagon.org
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Founded in 1843
Bill JohnsonPresident
Elmer Marks, Jr. President Pro-Tem
Joseph W. Erickson Manager
MarciaAho-BlackClerk/Treasurer TRUSTEESDianne Kattelus Tom Banse John Hamm John Cane Tony Smydra |
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AUTHORIZATION FOR DIRECT PAYMENT (ACH)
I authorize the Village of Ontonagon and the financial institution named below to initiate entries to my checking/savings account. This authority will remain in effect until I notify you in writing to cancel.
Begin Date:__________________________ End Date: ____________________________
________________________________________________________________________________ Name of Financial Institution Branch
_________________________________________________________________________________ City, State, Zip Phone Number
_________________________________________________________________________________ Customer Signature Date
_________________________________________________________________________________ Customer Name (please print)
________________________________________________________________________________ Customer Billing Address (please print)
________________________________________________________________________________ Customer Telephone Number
Account Number: Checking or Savings
Financial Institution Routing Number ________________________________________________ (Contact your bank for this nine-digit number)
Funds will be withdrawn from your account on the 15th of each month.
RETAIN THIS PORTION FOR YOUR RECORDS
On this date I authorize the Village of Ontonagon at 315 Quartz Street in Ontonagon, Michigan 49953 to initiate electronic entries to my checking/savings account and have agreed to the terms listed on the authorization. I may revoke my authorization with the Village at any time by writing to the address above.
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The Village of Ontonagon is an equal opportunity provider and employer. Complaints of discrimination should be sent to: USDA, Director, Office of Civil Rights, Washington, DC 20250-9410 . |
