Common Contracts
1 similar Authorization Agreement for Pre-Authorized Payments (Ach Debits) contracts
NURSING FACILITY QUALITY ASSESSMENTAuthorization Agreement for Pre-Authorized Payments (Ach Debits) • July 11th, 2008
STEP 1 NURSING FACILITY NAME FEDERAL EMPLOYER IDENTIFICATION NUMBER FACILITY NAME & ADDRESS NUMBER AND STREET ADDRESS ADDRESS (continued) CITY/TOWN STATE & ZIP CODE STEP 2 INITIAL, CHANGE, OR Check the type of request: INITIAL REQUEST CHANGE REQUEST REVOKE AUTHORIZATION REVOCATION STEP 3 DEPOSITORY (BANK) INFORMATION DEPOSI- TORY INFORMA- TION Depository (Bank ) Name Depository (Bank)Routing& Transit # Name on Depository Account FEIN/SSN on Depository (Bank)Account DepositoryAccount Account Type Savings Checking Number (check one) YOU MUST PROVIDE A COPY OF A VOIDED CHECK OR A SAVING WITHDRAWAL SLIP FOR THIS ACCOUNT. STEP 4ACH AUTHO- RIZATION This authorization is to remain in full force and effect until the STATE has received written notice from me (or either of us) of its termina- tion in such time and in such a manner as to afford the STATE and DEPOSITORY a reasonable opportunity to act on it.By signing below, I hereb
