pines          HIGHLANDS POLICIES

AUTHORIZATION AGREEMENT FOR AUTOMATIC DEBITS (ACH DEBITS)

  I authorize Highlands Cooperative Association, Unified Management Services, (hereinafter referred to as the Company) to make pre-authorized withdrawals on the fifth day of each month to Comerica Bank.  If the fifth falls on a weekend the withdrawal will be done the next business day.

 I authorize the Depository Financial Institution listed above to accept these withdrawals.  I also understand that adjusting entries may be made to correct any errors in the withdrawals.  It is agreed that these withdrawals and adjustments may be made electronically and are bound by the rules of the Michigan Automated Clearing House Association.  This authorization is to remain in effect until I provide a written notice of termination to the Company.

 Fill in the following information required (please print) and sign where the signature is needed.

             Name:               ________________________________________________

             Address:           ________________________________________________

                                     Lansing, MI 48911

             Signature:  ______________________________________  Date:  _________________

 

The following needs to be attached to this form when you return it to the Office:

              CHECKING ACCOUNT-a voided check

                 SAVINGS ACCOUNT-deposit ticket (must write savings account on deposit slip)

  

 

Office Use Only

 

 

Property:  Highlands Cooperative Association   #550

 

ID #:  ______

 Amount:  $__________