ACH Debit Form ACH Agreement NOTE: A MINIMUM ANNUAL DONATION OF $100 TO UNITED WAY OF WELD COUNTY IS REQUIRED TO USE THE ACH DIRECT DEPOSIT OPTION.Donor Name(Required) Email(Required) I hereby authorize United Way of Weld County to initiate debit entries to my(Required) Checking Account Savings Account Indicated below as the depository financial institution (e.g., bank) named below; hereafter called DEPOSITORY, and to debit the same to such account. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law.Depository Name(Required) Depository City(Required) Depository State(Required) Branch(Required) Routing Number(Required) Account Number(Required) Amount $(Required) Debit my account(Required) Monthly Quarterly One-Time Debit my account on(Required) 1st of the month 15th of the month 30th of the month Please upload a copy of voided check(Required)Max. file size: 300 MB.Consent(Required) I authorize United Way of Weld County to debit my account. This authorization is to remain in full force and effect until United Way of Weld County has received written notification from me of its termination in such time and in such manner as to afford United Way of Weld County and the DEPOSITORY a reasonable opportunity to act on it.Name(Required) Date(Required) MM slash DD slash YYYY Debit authorizations MUST provide that the receiver may revoke the authorization only by notifying the originator in the manner specified in the authorization. Please notify United Way of Weld County IN WRITING to discontinue your ACH including your signature. Thank you so much for your generosity. We appreciate your caring and support. Δ
