Safety OS - Direct Deposit Applicant Preview

ACBXpress Corp

Direct Deposit Authorization

I authorize ACBXpress Corp to deposit payments owed to me into the account identified below and, when permitted by law, correct an erroneous credit.

This authorization remains effective until I provide written notice allowing reasonable time to act. I certify that I am an authorized owner or signer on this account and that the information supplied is accurate.

Account holder

Enter the account exactly as it appears at the financial institution.

Name on account

Account ownership

Personal account Business account

Account type

Checking Savings

Financial institution

Provide the bank information associated with this account.

Bank name Bank phone, optional

Bank street address

City State ZIP code

Deposit account

Use the numbers from a check or your bank's account details.

Routing number Exactly 9 digits Account number 4 to 17 digits

Authorization and signature

Review the information above, then sign this authorization.

Date Typed signature

NATE RICHARDS

I authorize direct deposit to this account and agree to sign this form electronically.