Cal driver flat bed doubles and vans
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*** *. ******* ****** ** Box *****
Fairbanks, AK 99701 Fairbanks, AK 99707
Member FDIC www.denalistatebank.com Equal Housing Lender I authorize Denali State Bank (DSB) to initiate the following authorization for Direct Payment. This authorization will remain in effect until I notify you in writing to cancel. Notification to cancel must be received by the bank at least three (3) business days prior to the scheduled payment date. To ensure payment is received on schedule, the funds will be withdrawn from the account one (1) business day prior to the payment date. I understand funds availability is my responsibility, and if the scheduled transaction is returned as insufficient funds, the transaction will not be attempted again until the next scheduled payment date. If you are requesting to debit a DSB account, we will debit funds as soon as they become available. DSB will not notify me that payment has not been made due to insufficient funds. If a payment recurring date falls on a weekend or holiday, payment will be made the prior banking day. Entries may not be initiated that violate the laws of the United States. This authorization is subject to the terms and conditions as stated in the Deposit Agreement.
Sending Bank Information
Bank Name Routing Number
Account Name Account Number
Account Type DDA SAV
Receiving Bank Information
Bank Name Routing Number
Account Name Account Number
Account Type DDA SAV Loan
Payment Information
Amount of
Payment
Beginning
Date
Recurring Pmt
Day of Month
Additional Information
Account to Charge Applicable Fees:
(SIGNATURE) (DATE)
(PRINT NAME) (TITLE, if applicable)
Bank Use Only
Received By Date
Processed By Date
Updated 6/5/18
AUTHORIZATION FOR DIRECT PAYMENT
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