City of Fontana’s Empowerment Revolving Loan Fund Program Administered by AmPac Tri-State CDC, Inc. dba Ampac Business Capital Authorization Agreement for Pre- Authorization Payment (Debit) Authorization Agreement for Pre-Authorization Payment (Debit) Page 1 of 1
I (We) authorize AmPac Tri-State CDC, Inc dba AmPac Business Capital to initiate debit entries payable to the account (described below) and bank (named below) to debit the amounts of such entries:
Periodically as such amounts become due, without further authorization (standing authorization);
Bank name
Address
City State Zip
Account: Checking Savings Other
Transit ABA
Transit routing number Check digit Account number information
*Check Digit is the Last Digit in the Routing Number*
Designated by Federal Reserve.
NOTICE: When completing account number information, insert a hyphen (-) for each Dash Cue Symbol (-) contained in the field and insert a number sign (#) for each “On Us” Cue Symbol (|’).
This form must be provided to AmPac Tri-State CDC, Inc. dba AmPac Business Capital prior to the 15th of the month for ACH changes/new accounts to be effective on the first of the subsequent month.
Account Name (as shown on Check)
[Date]
Signature Date
[Date]
Signature 2 (as required) Date
Attached Voided Check (Required): Yes No
*If a Voided Check is not available, a screenshot from the Mobile Banking App reflecting the Routing and Account Number will Suffice*
For AmPac Business Capital Use Only:
CDC Number: 09-697
Borrower’s Name: [Borrower’s Legal Name]
Loan Type: [Loan Type]
Loan Number: [Loan Number]