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Authorization Agreement for Direct Payments (ACH Credits)

  1. StormLakecmyk-nobackground
  3. (For 1099 purposes)
  4. Incorprated:*
  5. Street~City~State~Zip Code
  6. I hereby authorize the City of Storm Lake, hereinafter called CITY to initiate credit entries to my account indicated below, for direct deposit of invoices .** I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law.
  7. Account type:*
  8. Street~City~State~Zip Code
  9. The CITY or any of the undersigned may cancel this authorization upon written notice to the other in such time and in such manner as to afford a reasonable opportunity to act on it.
  10. Office Use Only
    Date form received________ Effective date __________________
  11. City of Storm Lake ~ 620 Erie Street ~ Storm Lake, IA 50588 ~ 712-732-8000
  12. Leave This Blank:

  13. This field is not part of the form submission.