|
Philipsburg |
(814) 342-3190 |
| Bellefonte | (814) 355-4749 |
| Clearfield | (814) 765-8730 |
| Lewistown | (717) 248-3717 |
J. J. POWELL, INC. FUEL DEBIT AUTHORIZATION
I (we) hereby authorize J. J. POWELL, INC. (THE COMPANY) to initiate entries to my checking/savings accounts at the financial institution listed below (THE FINANCIAL INSTITUTION), and, if necessary, initiate adjustments for any transactions credited/debited in error. This authority will remain in effect until THE COMPANY is notified by me (us) in writing to cancel it in such time as to afford THE COMPANY and THE FINANCIAL INSTITUTION a reasonable opportunity to act on it.
____________________________________________________________________
(Name of Financial Institution)____________________________________________________________________
(Address of Financial Institution—Branch, City, State, & Zip)______________________________________ ______________________________
(Signature) (Date)___________________________________________ (Name – PLEASE PRINT)
_______________________________________________________________
________ (Address—PLEASE PRINT)Payment Amount
will be equal to your monthly Easy Pay amount.Checking/Savings Account Number
:________________________________________Financial Institution Routing Number:_______________________________________ (Look between these symbols 1: :1 on the bottom left of your check)
**Payments will be drafted the first business day after the 8th of each month.
***Please attach a voided check when submitting your authorization to ensure that we have the correct account number.
J. J. Powell, Inc., PO Box 30, Philipsburg, PA 16866