ACH | startvirtual.com

CONSUMER AUTHORIZATION FOR DIRECT DEPOSIT VIA ACH (ACH CREDITS)

Direct Deposit via ACH is the deposit of funds to a consumer’s account, for example, payroll, employee expense reimbursement, government benefits, tax and other refunds, annuities, and interest payments.

First Name

Last Name

Terms

I (we) hereby authorize {name-1-first-name} {name-1-last-name} (“StartVirtual”) to electronically credit my (our) account (and, if necessary, to electronically debit my (our) account to correct erroneous credits1 ) as follows.

Select OneChecking AccountSavings Account

Bank Info

at the depository financial institution named below (“DEPOSITORY”). I (we) agree that ACH transactions I (we) authorize comply with all applicable law.

Depository Name

Routing Number

Account Numberfor amex cvv is on the front

Name(s) on the Account

Cancellation

I (we) understand that this authorization will remain in full force and effect until I (we) notify StartVirtual via email that I (we) wish to revoke this authorization. I (we) understand that StartVirtual requires at least 30 days prior notice in order to cancel this authorization.

Email Address

Signature