Form 3 - Electronic Funds Transfer Authorization Agreement (ACH Debits & Credits)

I hereby authorize Central Prairie Co-op to initiate debit or credit entries to my account indicated below and the financial institution named below. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law.
Name of Account with Central Prairie Co-op
Your phone Number
Date
Address
Address City State ZIP
Financial Institution Name
Routing Number
Account Number
Type of Account
- Checking
- Savings
Address
(Financial Institution Address City State ZIP
This authority is to remain in full force and effect until Central Prairie Co-op has received written notification from me of its termination in such time and manner as to afford Central Prairie Co-op and the above mentioned Financial Institution a reasonable opportunity to act on it.
Print Individual Name
Signature
(PLEASE ATTACH A DEPOSIT SLIP OR VOIDED CHECK HERE)
Accepted file types: jpg, png, pdf.

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