You are on page 1of 1

DIRECT DEPOSIT AUTHORIZATION FORM New Authorization Payer Information: Name : RL Electronics, Inc Address: 440 Montgomery St.

San Francisco California 94103 Phone Number: 4159591255 Fax Number: 4158659453 Payee Information: Name : Dorian Mayhew Rothschild Address: 60 Arthur St. San Rafael California 94901 Phone Numbers: Home: 4158432331 Work: 4158432331 SSN: 123-45-6789 Identification Number: 123456789

Financial Institution: Name : Redwood Bank Address: 35 Palm Circle Dr., Corte Madera, California, 95422 Phone Number: 4157745543 Fax Number: 4158842354 Bank Routing Number: 123456789 Account Number: 384534 Type of Account: Checking Amount to Deposit: 100% Attachments: Attached to this Authorization is a cancelled check for my account. I authorize RL Electronics, Inc to deposit all payments due to me in the account(s) named herein. I further authorize RL Electronics, Inc the authority to make debits or take other corrective actions, if necessary, in relation to any deposit made by RL Electronics, Inc into the account(s).

Signed:

____________________________________________ Dorian Mayhew Rothschild ________________

Dated:

This is a RocketLawyer.com Legal Document

You might also like