ACH Form – ICHA - Irvine Campus Housing Authority

IRVINE CAMPUS HOUSING AUTHORITY AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (ACH DEBITS)

Please complete and sign this authorization form. Attach a voided check and return to Accounting Dept - 1083 California Avenue, Irvine, CA 92617. Your designated Financial Institution must be capable of processing our automatic debit transaction. Please confirm this with your Financial Institution.

Customer Name(Required)

University Hills Account Number

Phone

Address(Required)

I (We) hereby authorize IRVINE CAMPUS HOUSING AUTHORITY, hereinafter called ICHA, to initiate debits to my account indicated below at the Financial Institution named below in the amount of my monthly ICHA bill.

Bank Name(Required)

Bank Account Number(Required)

Routing Number(Required)

Upload voided check or screenshot of full account and routing numbers(Required)

Max. file size: 100 MB.

This authorization is to remain in full force until ICHA has received written notification from me (or either of us) of its termination in such a manner as to afford ICHA and the Financial Institution reasonable opportunity to act upon it.

Signature(s)(Required)

Signature 2

Date(Required)

Please continue to make your payments by check until you receive notification of the Direct Debit start date from our Accounting Department.

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ACH Form – ICHA

IRVINE CAMPUS HOUSING AUTHORITY AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (ACH DEBITS)

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