Account Number:

I (We) hereby authorize the City of McCook, hereinafter called COMPANY, to initiate debit entries to my (our) bank account indicated below at the depository financial institution named below, hereinafter called DEPOSITORY, and to debit the same to such account. I (We) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of the United State Law.

DEPOSITORY ACCOUNT HOLDER INFORMATION

Start Date:*

Name:*

Address:*

Phone:*

DEPOSITORY ACCOUNT INFORMATION

Bank Name:*

Branch:

City:

State:

Zip:

Routing Number:*

Account Number:*

This authorization is to retain in full and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.

Electronic signature:*

NOTE: All written debit authorizations MUST provide that the receiver may revoke the Authorization only by notifying the originator in the manner specified in the Authorization.

ATTACH VOIDED CHECK *

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