BANK ACH AUTHORIZATION RELEASE FORM

Retired Firefighters Association of Washington D.C.

  

I,                                                                    , hereby authorize Professional Outsourcing Solutions Corporation (ProSource) to initiate ACH (automated clearing house) transfer entries for the following depository:

 

Financial Institution:_____________________________________________

 

Address: ______________________________________________________

                                        

City, State, Zip:_________________________________________________

 

Routing & Transit Number:________________________________________

 

Bank Account Number:___________________________________________

 

Type of Account:  Checking _____     Savings ______       Other ______

 

Effective Date:__________________________________________________

 

 Authorized By:__________________________________________________

                                                (Please print name)

 Date: _______________        _____________________________________

                                                (Signature)

  

Please attach a voided check here 

 

ALL FORM(S) SHOULD BE MAILED TO THE BELOW ADDRESS:

 

ProSource

P.O. Box 759198

Baltimore, MD  21275-9198