Circle City ABA Direct Deposit Form

Direct Deposit Authorization 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
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

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature (Use your mouse or finger to sign below)
Should be Empty:

Direct Deposit Authorization Form