Direct Deposit | Holistic Health Associates

AUTHORIZATION AGREEMENT FOR DIRECT CREDITS

(ACH CREDITS)

Direct Deposit via ACH is the deposit of funds to a consumer’s account, for example, payroll, employee expense reimbursement, government benefits, tax and other refunds, annuities, and interest payments.

I hereby authorize Holistic Health Associates to electronically credit my/our account (and, if necessary, to electronically debit my/our account to correct erroneous credits¹) as follows:

PRINT ALL INFORMATION CLEARLY

BANK ACCOUNT INFORMATION(Required)

(select one) at the depository financial institution named below (Depository Name). I/We agree that ACH transactions I/we authorize comply with all applicable law.

Checking Account

Savings Account

DEPOSITORY NAME(Required)

ROUTING NUMBER (9 digits)(Required)

ACCOUNT NUMBER(Required)

NAME(S) (on bank account)(Required)

Amount of credit(s) or method of determining amount of credit

I/We understand that this authorization will remain in full force and effect until I/we notify holistic Health Associates in writing that I/we wish to revoke this authorization. I/We understand that Holistic Health Associates requires at least 30 days prior notice in order to cancel this authorization.²

Date(Required)

Signature(Required)

Name

First Last

¹The NACHA Operating Rules do not require the consumer’s express authorization to initiate Reversing Entries to correct erroneous transactions. However, Originators should consider obtaining express authorization of debits or credits to correct errors.

² Written credit authorizations must provide that the Receiver may revoke the authorization only by notifying the Originator in the time and manner stated in the authorization. The reference to notification should be filled with a statement of the time and manner that notification must be given in order to provide company a reasonable opportunity to act on it (e.g., “In writing by mail to 100 Main St., Anytown, NY that is received at least three (3) days prior to proposed effective date of the termination of authorization).