Non-Federal Direct Deposit Enrollment Request Form

Please print and complete ALL the information below.

Name: ________[esiggravity formid="8" field_id="1" display="value" ]_______

Address: ____[esiggravity formid="8" field_id="2" display="value" ]_____________

Name of Bank: ____________[esiggravity formid="8" field_id="4" display="value" ]______________

Account #: ________[esiggravity formid="8" field_id="6" display="value" ]_______

9-Digit Routing #: _______[esiggravity formid="8" field_id="7" display="value" ]________

Type of Account:  _____[esiggravity formid="8" field_id="8" display="value" ]_____


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

[esiggravity formid="8" field_id="11" display="value" ]


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: ___[esiggravity formid="8" field_id="1" display="value" ]______________________

Date: ___July 17, 2024____________

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Signature Certificate
Document name: Non-Federal Direct Deposit Enrollment Request Form
lock iconUnique Document ID: 28245e4a26d4f8fe129290f3e4b53829cc2d2830
Timestamp Audit
December 20, 2021 6:57 pm EDTNon-Federal Direct Deposit Enrollment Request Form Uploaded by Brandilyn Cox - [email protected] IP