Check Authorization Form

There is no fee associated with this check draft authorization. However, there is a service fee added to all returned items of $25.00 or the maximum allowed by law.

Customer Information

Your Name (Authorized User)*

Name as imprinted on check*

Customer Number
(Debtor Id Number on Notice)

Home Phone*

Work Phone*

Bank Information

Bank Routing Number*
(9 digit number on bottom of check)

Bank Account Number*

Bank Name

Bank City, State

Check Number To Use

Amount Authorized

Date We Can Issue