Non-Federal Direct Deposit Enrollment Request Form
Please print and complete ALL the information below.
Name of Bank: __________________________
Account #: _______________
9-Digit Routing #: _______________
Type of Account: __________
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: _________________________
Date: ___January 26, 2022____________
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Non-Federal Direct Deposit Enrollment Request Form
Agree & Sign