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Authorization Agreement for ACH Debit

  1. National Payment Solutions

    506 Manchester Expressway, Suite A-12
    Columbus, GA 31904
    888-554-9356

  2. Please input all fields that are not required by hand after printing.

  3. Authorization*

    I hereby authorize NPS hereinafter called COMPANY, to initiate debit entries to my account indicated below and the depository named below hereinafter called DEPOSITORY to debit the same such account. Dishonored payments can be represented electronically for the check amount and service charges as permitted by state laws.

  4. Agreement*

    This agreement is to remain in effect until COMPANY and DEPOSITORY have received written notification of termination 30 days prior in advance.

  5. Important Notice*

    Transfer will occur on the 1st of each month, or the next business day if the 1st falls on a holiday or weekend.

  6. Instructions to Submit the Form

    Print the completed form, attach a copy of voided check, and return to:
    City of Groveland
    156 S. Lake Avenue
    Groveland, FL 34736
    352-426-2141 ext. 221

  7. For Personnel Use Only

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