ACH Debit Authorization Form

Authorized Agreement

I hereby authorize Vermont Information Processing (VIP) to initiate a one-time debit and any
necessary correcting credit entries to the account indicated below and the depository named below to debit the same to such account.

The dollar amount showing due on open invoice(s) selected below will be processed on the following business day following submission of this form.

Account ID/Retailer ID (as it appears on your invoices) *

Company Name *

Payment Amount: *

Date transaction will be processed: *

Additional notes that should be considered:

If this payment is submitted after 3:00 PM, payment will be processed on the following business day.

Name that appears on bank statement: *

Depository Name (Name of Bank): *

Please select the type of account: *

Checking

Savings

Is this a business account? *

Yes

Routing/Transit Number (9-digit number) *

Account Number: *

By checking “Yes” and opting to pay by electronic debit against the bank account specified above, I agree and stipulate to all statements:

I am the legal owner, have power of attorney, or have legal authority in relation to the bank account specified above to be used for payment.

Such bank account is open, validly issued, in good standing and able to accept electronic debits.

Vermont Information Processing or its agent is authorized to electronically debit the bank account shown above, and if necessary, to credit such account to correct any erroneous debits using an Automated Clearing House (“ACH”) debit entry.

This ACH debit authorization will remain in full force and effect for this single debit entry only.

Vermont Information Processing or its agent may re-debit my account for the payment in the event such is dishonored by my financial institution, and is additionally authorized to charge any return item processing fees.

For inquiries relating to this electronic debit authorization, including revocation of this authorization, I may contact Vermont Information Processing at 802-655-9400 x2923. *

Yes, I authorize this transaction.

Full Name of Authorized Representative: *

Email Address *

Please print this page if you would like a copy of this authorization for your records.