ACH .pdf

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Title: Microsoft Word - ACH Authorization Form 03.17.14.doc

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ACH Authorization Form
315 Upland Rd.
Kennett Square, PA 19348
Email: AgentRelations@PayGoDistributors.com

PLEASE CHECK ONE:

NEW*

CHANGE

CANCEL

*If NEW box is checked, please submit form W-9

Payee Information: Agent/Retailer
Contact Person ___________________________________________________________________
Billing Address ____________________________________________________________________
City, State, Zip ____________________________________________________________________
Phone Number ____________________ Email ______________________________________

ACCOUNT INFORMATION:
Account Type:

Checking

Savings

Exact Name on Acct ____________________________________ Bank Name _______________________________________
Bank Routing Number __________________________________ Account Number ____________________________________

AUTHORIZATION:
I (we) hereby authorize DK Distributors DBA PagGo Distributors, LLC to credit this bank account due to me, in accordance with the
Agreement for payment due to me (us) on dates specified in accordance with the Agreement.
I hereby authorize DK Distributors DBA PagGo Distributors, LLC to debit this bank account for any invoice (customer payments,
expenses etc.) or any reimbursement due DK Distributors DBA PagGo Distributors, LLC including any errors for overpayments paid to me
(us).
I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify DK Distributors DBA
PagGo Distributors, LLC in writing of any changes in my account information or termination of this authorization at least 10
days prior to the next billing date. If the payment date falls on a weekend or holiday, I understand that the payment may be
executed on the next business day. I understand because this is an electronic transaction, these funds may be withdrawn from
my account any day after approval of the amount authorized by me in advance, after which I can guarantee sufficient funds are
in the account. In the case of an ACH transaction being rejected for Non-Sufficient Funds (NSF) I understand that DK
Distributors DBA PagGo Distributors, LLC may at its discretion attempt to process the charge again. I acknowledge that ACH
transactions to my account must comply with the provisions of U.S. law. I agree not to dispute this recurring billing with my
bank so long as the transaction corresponds with the terms indicated in this authorization form.

Signature

Date


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