Est. 1972 2410 17th St., N.W. • Suite 100 • Adams Alley • Washington, D.C.

20009
Serving DC, MD and VA 202-667-7006 • www.housingetc.org

Authorization Agreement For

Automated Clearing House Transactions (ACH Credits)
ACH Authorization
Individual /
Company Name:

I (we) hereby authorize: Housing Counseling Services hereinafter called ORGANIZATION, to

initiate credit entries and to initiate, if necessary, debit entries and adjustments for any credit entries in error to my (our)
Checking Savings account (select one) indicated below and the depository named below, hereinafter called
DEPOSITORY.

Bank Information
DEPOSITORY Branch:
NAME: (if applicable)

City, State, ZIP:

Transit/ABA No:
Account #:
(“Routing #”)

I affirm that I am authorized to sign this agreement on behalf of the entity listed above. This authority is to remain in full
force and effect until ORGANIZATION has received written notification from me (us) of its termination in such time
and in such manner as to afford ORGANIZATION and DEPOSITORY a reasonable opportunity to act on it.

Name(s): SSN or
Please print TIN:

Signature(s) Date
Email address:_______________________________________ Phone Number:___________________________

Address: ____________________________________________

I (we) wish for this transaction to take place starting on: _ ______________________

CHECK ONE: I am not currently participating in the Automated Payment Program.

ADD – Credit the account shown.
I am currently participating in the Automated Payment Program.
CHANGE – Change financial institutions and/or account number.

TAPE VOIDED CHECK HERE