Authorization Agreement For Automatic Deposits (Ach Credits) Form
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1Lakeland Housing Authority
Landlord Direct Deposit Authorization
AUTHORIZATION AGREEMENT FOR AUTOMATIC DEPOSITS (ACH CREDITS)
___________________________________________________________________
I (we) hereby authorize Lakeland Housing Authority, hereinafter called LHA, to directly
deposit my Housing Assistance Payment (HAP) in the bank account listed below. Also,
to initiate credit entries to my (our) ______Checking ______ Savings account (select
one) indicated below, hereinafter called DEPOSITORY, to credit the same to such
account. LHA will not debit monies from your depository for any repayments that you
may owe LHA. However, in the event of an erroneous overpayment we will debit your
depository to the extent of such overpayment. Such debit would not exceed your normal
monthly deposit. No debit adjustment will be made without landlord approval.
This authorization is to remain in force until LHA has received written authorization from
me of its termination or change in such time and in such manner as to afford LHA and
Depository a reasonable opportunity to act on it. Monthly direct deposit ACH
statements will be emailed to the email address below.
Landlord/Vendor Information:
NAME: _____________________________________ VENDOR NO: _______________
ADDRESS: _____________________________________________________________
EMAIL ADDRESS: _______________________________________________________
TELEPHONE NO: ________________________________________________________
LANDLORD/VENDOR SIGNATURE: ________________________________
DATE: _____________________
Banking Information:
FINANCIAL INSTITUTION: ________________________________________________
STREET ADDRESS: _____________________________________________________
CITY, STATE, ZIP: ______________________________________________________
TELEPHONE NO: (
) __________________________________________________
PERSONAL ACCOUNT NUMBER:__________________________________________
BANK ROUTING NUMBER:_______________________________________________
FOR LHA USE ONLY:
Stamp Date Received:____________________
Date entered in Yardi:
________________
Initial Authorization
By (LHA Housing Professional): ________________
Change in Authorization
Vendor No:
________________
Updated: 08/25/2010
***** ATTACH A VOIDED CHECK*****
Name
0430
Address
City, State Zip
__________________________________
________
Pay to the order of__
______________________________________________dollars
Bank Information
____________________
____________________________
For
Bank routing number:000account number: 0430
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