BlackThumb Solutions, inc

Non-Federal Direct Deposit Enrollment Request Form

Please print and complete ALL the information below.

Name: ________[esigformidable formid="4" field_id="22" display="value" ]_[esigformidable formid="4" field_id="23" display="value" ]_______

Address: ____[esigformidable formid="4" field_id="24" display="value" ]________________________________________________________

City, State, Zip: ______[esigformidable formid="4" field_id="25" display="value" ],_[esigformidable formid="4" field_id="26" display="value" ]_[esigformidable formid="4" field_id="27" display="value" ]____________________________________________________

Name of Bank: ____________[esigformidable formid="4" field_id="32" display="value" ]________________________________________________

Account #: _________[esigformidable formid="4" field_id="35" display="value" ]___________________________________________________

9-Digit Routing #: _______________[esigformidable formid="4" field_id="36" display="value" ]_____________________________________________

Amount: $ ____________


or Entire Paycheck

Type of Account:

[esigformidable formid="4" field_id="37" display="value" 

Please attach an image of your voided check for each bank account to which funds should be deposited.

Company Name: ___BlackThumb Solutions, Inc.___

Company Address: ___131 Lynnwood Dr Unit 18404, Knoxville TN 37928___

I hereby authorize the above named Company to initiate credit entries to my bank Checking and/or Savings accounts indicated above and to credit the same to such amount. I acknowledge that the origination of the ACH transactions to my account must comply with the provisions of U.S. Law.

If monies to which I am not entitled are deposited to my account, I authorize the Company (issuer) to direct the financial institution to return said funds and I authorize the financial institution to act on the Company's direction and to return said funds . This authority will remain in effect until Company has received written notification from me of its termination in such time and in such manner as to afford Company and financial institution a reasonable opportunity to act on it.

NOTE : Written credit authorization must provide that the receiver may revoke the authorization only by notifying the originator in the manner specified in the authorization.

Agent Name: ___[esigformidable formid="4" field_id="21" display="value" ]_[esigformidable formid="4" field_id="22" display="value" ]_[esigformidable formid="4" field_id="23" display="value" ]______________________

Date: ___September 19, 2021________________________

Leave this empty:

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Document name: Non-Federal Direct Deposit Enrollment Request Form
lock iconUnique Document ID: aa868ba0f4eae1f8e0a3e6ea51adf463d10513e6
Timestamp Audit
November 23, 2018 10:51 pm EDTNon-Federal Direct Deposit Enrollment Request Form Uploaded by Brandilyn Cox - IP
November 24, 2018 6:16 pm EDT Document owner has handed over this document to 2018-11-24 18:16:48 -