Circle City ABA Direct Deposit Form

I hereby authorize Circle City ABA, hereinafter called COMPANY, to initiate credit entries to my account indicated below and the financial institution named below, hereinafter called FINANCIAL INSTITUTION, to credit the same to such Account. I acknowledge that the origination of EACH transaction to my account must comply with the provisions of U.S. law.

Circle City ABA Office Location*

NOTE: Your entire check will be deposited into your primary account listed below. If you choose to have the optional secondary account - you must enter a specific dollar amount to be deposited into your secondary account, the remaining balance will be deposited into your primary account.

Type of Primary Account*

Financial Institution Name*

Primary Account Number*

Primary Routing Number*

Would you like to enter information for secondary deposit account*

YesNo

Secondary Account (optional)*

Financial Institution Name*

Amount to deposit into Secondary Account (THIS MUST BE A SPECIFIC WHOLE DOLLAR AMOUNT)*

Secondary Account Routing Number*

Secondary Account Number*

This authority is to remain in full force and effect until COMPANY has received written notification from me of its termination in such time and manner as to afford COMPANY and FINANCIAL INSTITUTION a reasonable opportunity to act on it.

Name*

First NameLast Name

Date*

Date

Signature (Use your mouse or finger to sign below)*

Direct Deposit Authorization Form