ACH Form
Authorization Agreement Direct Payments
 
Rebeltec Communications LLC
P.O. Box 10, Kit Carson, CO  80825
(719) 767-8902 ~ www.rebeltec.net ~ tech@rebeltec.net

     I (we) hereby authorize Rebeltec Communications LLC, hereinafter called COMPANY, to debit entries to my (our) account indicated below and the Financial Institution named below, hereinafter called FINANCIAL INSTITUTION, to debit same to such account. I (we) acknowledge the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law.
 


(Financial Institution Name)
(Branch)
 



(Address)
(City, State)
(Zip Code)
 


(Routing/Transit Number)
(Account Number)
 
Type of Account: _________Checking  ___________ Savings
 
     This authority is to remain in full force and effective until COMPANY has received written notification from me (or either or us, if a joint account) of its termination in such time and manner as to afford COMPANY and FINANCIAL INSTITUTION a reason able opportunity to act on it.
 
(If account requires two signatures
please fill out information below)
 


(Print Individual Name)
(Print Individual Name)
 


(Signature)
(Signature)
 


(Date)
(Date)
 
PLEASE ATTACH A VOIDED CHECK (OR A COPY) TO THIS FORM