DIRECT DEPOSIT AUTHORIZATION

First Name: *

Last Name: *

Mobile Phone: *

Personal Email: *

Enter the eMail Address that is on your Billing for Verification.

Street Address: *

City: *

State: *

Postal Code/Zip Code: *

AGENT/BROKER CREDENTIALS

What Is Your Agent/Broker Number: *

Enter your TruPowur Three Digit Extension Number (Sales Code) for verification.

What Type of SaaS License Do You Hold: *

Agent SaaS License

Broker SaaS License

What Is Your TruPowur eMail Address: *

BANK ACCOUNT INFORMATION

Name On The Account: *

Address On The Account: *

9-Digit Routing Number: *

Account Number: *

Name of Bank/Financial Institution: *

Type of Account: *

Checking

Savings

Bank Account Type: *

Personal Account

Business Account

Upload a Voided Check for the Account to which Funds should be Deposited. *

Upload a Voided Check for the Account to which Funds should be Deposited.

AUTHORIZATION AGREEMENT

I authorize TruPowur, Inc. to make electronic deposits of payments to the financial institution above. This authority will remain in effect until I have given written notice of termination or until TruPowur, Inc. has notified me that this service has been discontinued. In the event of changes to my information.
I understand that I must give a 30-day advance notice to allow reasonable time for my instructions to be executed. If an incorrect amount should be entered into my account, I authorize my bank and TruPowur, Inc. to make the appropriate adjustment. If you provide either a voided check or a bank statement verifying your ACH routing and account numbers, deposits will take effect with the payment processed. If no voided check or bank statement is provided, then your Direct Deposit agreement will become effective after approximately two weeks. A check may be issued until the agreement & verification takes effect.

Authorized Signature: *

Clear

Name of Authorized Signature Above: *

Date: *

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