AUTHORIZATION FOR DIRECT PAYMENT

I authorize PossAbilities of Southern Minnesota and the financial institution named below to initiate entries to my checking account. This authority will remain in effect until I notify you in writing to cancel it. 

(ADDRESS – PLEASE PRINT)

(Name of Financial Institution)                                           (Branch)

(City)                                                 (State)                                  (Zip COde)

(SIGNATURE)                                                                                    (DATE)

Select  ___  Checking   or  ___ Savings

Account No.___________________________________________________

Financial Institution Routing Number_______________________________________ (9 digits)

                                                            (on the bottom left of your check)

Payment Amount $_____________to be deducted on the

q  1st of each month

q  15^th of each month

**ATTACH VOIDED CHECK HERE FOR CHECKING ACCOUNT OR CONTACT YOUR FINANCIAL INSTITUTION FOR CORRECT SAVINGS ACCOUNT INFORMATION.