AUTHORIZATION AGREEMENT FOR AUTOMATIC DEPOSIT. I authorize American National Insurance Company and the bank listed to deposit my commissions to the account name below. This authority will remain in effect until I provide a new authorization or cancellation. The company reserves the right to initiate debit entries for recovery of sums due to credit entries processed in error, if determined within the week of the credit entry. A Voided Check must be submitted with your request for Direct Deposit. AGENT NAME SSN # AGENCY # DEPOSITORY (BANK) NAME ADDRESS CITY, STATE, ZIP / / CHECKING ACCOUNT # SAVINGS ACCOUNT # 9 DIGIT ROUTING # 9 DIGIT ROUTING # CREDIT UNION MONEY MARKET ACCT. % TO CHECKING ACCT. % TO SAVING ACCT. (Name as it appears on checking account) (Name as it appears on savings account) If contract file is submitted electronically through nomoreforms, a voided check should be scanned and submitted as an attachment to the file or you may fax a copy to 0-000-000-0000. If submitting voided check by fax, please include a cover sheet indicating original file was submitted through nomoreforms and list applicant’s name. EFT PROCEDURES Once you have signed up, your check will be automatically deposited into your checking and/or savings account approximately 3-4 weeks from the day the Home Office received the request. You will receive a "DEPOSIT ADVICE" form which will replace your check stub. This form will show your gross and net pay for the month and year-to-date. It will also show other deductions. For Agent Use Only Form 4589 Rev. 01/09 AMERICAN NATIONAL INSURANCE COMPANY GENERAL AGENT COMPENSATION SCHEDULE Life Products Ages 1st Year Target Premium Yr. 2 - 3 Yr. 4 - 5 Additional Deposits/Renewals Yr. Yr. 6 - 7 8 - 10 Yr. 11+ 1 This compensation schedule shall cancel and supersede all previously effective Compensation Schedules and Paid Production requirements, but it shall not impair your rights to commissions or fees, if any, earned under the provisions of any prior schedules. Commissions and fees are expressed as a percentage of premiums paid unless otherwise noted. Schedule consists of 5 pages total. ANICO Indexed UL2 18-69 80 2 2 2 2 0.6 excess 18-69 2 2 2 2 2 0.6 70-85 75 2 2 2 2 0.6 excess 70-85 2 2 2 2 2 0.6 ANICO Executive UL2 0-69 80 2 2 2 2 2 excess 0-69 2 2 2 2 2 2 70-85 75 2 2 2 2 2 excess 70-85 2 2 2 2 2 2 Affinity 7 Par Whole Life 0-69 80 2 2 2 2 0.7 70-79 60 2 2 2 2 0.7 80-85 30 2 2 2 2 0.7 ANICO Signature Term (Annual policy fee is non-commissionable) ART 18-65 80 - - - - - 10 year ter...
AUTHORIZATION AGREEMENT FOR AUTOMATIC DEPOSIT. This form authorizes Early Learning Coalition of Polk County to deposit provider payments directly into the bank account listed below. This form also authorizes the reversal of any incorrect entries made in error related to the Florida Subsidized Child Care program or Florida Voluntary Pre-Kindergarten program. Please fill in ALL the information below to set up a permanent ACH wire. New Application Change Application Provider Name Provider Address City State Zip Daytime Phone Tax ID/SSN Provider Fax Number E-Mail Address Name of Bank Bank ABA/Routing Number Name of Bank Account Holder Bank Account Number Checking or Saving Account Telephone Number of Bank/Contact Person Please attach a voided check or deposit slip to complete this application Signature of Authorized Signer Print Name of Authorized Signer Please complete form and return to: Early Learning Coalition of Polk County 000 X. Xxxxxxxx Xxx., Xxxxx 000
AUTHORIZATION AGREEMENT FOR AUTOMATIC DEPOSIT. I hereby authorize the San Antonio Housing Authority (SAHA) to make deposits in the account located at (name of Depository Financial Institution, hereinafter referred to as DFI) _ and authorize the DFI to accept these deposits. Adjusting entries to correct errors are also authorized. It is agreed that these deposits and adjustments may be made electronically which is consistent with the requirements of Section 205.9(b) of Federal Regulation E under the Rules of the National Automated Clearing House Association (NACHA). This authorization will remain in effect until written notice of termination is given to the San Antonio Housing Authority. Name of the Financial Institution Name on Account Account Number Routing / Transit Number Account Type SSN/Tax I.D. Number Telephone Number Printed Name Signature Date: Email Address Please attach a voided check or an account verification letter signed by an authorized bank representative for verification purposes. RETURN TO: xxxxxxxx_xxxxxxx@xxxx.xxx
AUTHORIZATION AGREEMENT FOR AUTOMATIC DEPOSIT. I (We) herby authorize Xxxxxx Financial to initiate Automated Clearing House credits and, if necessary, make debits for any entries made to my account in error. AGENT INFORMATION Agent or Agency Name: Social Security number/Tax ID number: Phone Number: Please indicate transaction type: Set-up Change Cancel Please indicate type of account: Checking Savings FINANCIAL INFORMATION Bank Name: Bank City: State: Zip: Bank phone number: Bank account number: Bank routing number: (Please provide the nine-digit routing number on your check, not the deposit slip) This authorization will remain in force until written notification of termination or change is received by Xxxxxx Financial in such time and in such manner as to afford Xxxxxx Financial opportunity to act on it. NOTE: Direct deposit set-up requires that the bank account and routing number must be verified for accuracy before any funds are transferred. For this reason, you may receive one or two commission checks that need to be cashed. Print Name: Signature: Date: Complete and fax this form to Xxxxxx Financial at 000-000-0000 PLEASE INCLUDE A COPY OF A VOIDED CHECK Form W-9(Rev. January 2003)Department of the Treasury Internal Revenue Service Request for Taxpayer Identification Number and Certification Give form to the requester. Do not send to the IRS. Print or type See Specific Instructions on page 2. Name Business name, if different from above Individual/ Check appropriate box: Sole proprietor Corporation Partnership Other } Exempt from backup withholding Address (number, street, and apt. or suite no.) Requester’s name and address (optional) City, state, and ZIP code List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Social security number – – Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. or Note: If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter. Employer identification number – Part II Certification Under penalties of perjury, I certify that:
AUTHORIZATION AGREEMENT FOR AUTOMATIC DEPOSIT. SFN is authorized to initiate direct deposit entries and to initiate, as and when necessary, to the following account(s): (Check one) Checking Account Savings Account EMPLOYEE BANK NAME: CITY, STATE _ ROUTING/ABA# ACCOUNT # PLEASE ATTACH A VOIDED CHECK TO ENSURE ACCURACY I wish to decline direct deposit and receive a paper check at this time. I understand that I may sign up for direct deposit at a later date.
AUTHORIZATION AGREEMENT FOR AUTOMATIC DEPOSIT. Of Child Care Provider Payments This form authorizes the Reimbursement agent to deposit child care provider payments directly into the bank account listed below and, if necessary, reverse any incorrect credit entries made in error related to the provider payments. I agree to resubmit this form immediately if this bank or bank account changes or if I decide to stop direct deposit. Check One: New Application Change Direct Deposit NO CHANGES – New Contract Year Information (Please do not complete form if there are no changes at this time) Child Care Provider Information: (please print clearly) Name of Provider or Business: Business Address: City: State: Zip: Daytime Telephone Number: - - Provider Identification Number: (Tax ID Number –or- SSN) Information on Financial Institution: Name of Bank: Bank Address: Bank’s City: State: Zip: Telephone Number of Bank: - - Checking Acct [ ] Savings Acct [ ] Bank Transit / Routing Number: (Ask Bank for the transit / routing number for direct deposit) Bank Customer Information: Bank Account Number: Name of Bank Account Holder (please print clearly: PLEASE ATTACH A VOIDED CHECK OR DEPOSIT SLIP (SAVINGS ACCOUNT ONLY) TO THIS APPLICATION
