| Company Name ____________________________________ Company ID#_____________________ |
| I (we) hereby authorize Lamotte Telephone Company, hereinafter called COMPANY, to initiate debit entries to my (our) _____Checking Account // _____ Savings Account (SELECT ONE) indicated below at the depository financial institution named below, hereafter called DEPOSITORY, and to debit the same to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law. |
| Depository Name___________________________________ Branch__________________________ |
| City ____________________________________State_________________Zip_________________ |
| Routing Number____________________________________ Account Number___________________ |
| This authorization is to remain in full force and effect until COMPANY has received written notificaiton from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it. |
| Name(s) _________________________________________ ID Number _______________________ |
| Date ___________________________________ Signature_________________________________ |
LaMotte Telephone Co - WiFi - PO Box 8, LaMotte, IA 52054
1-866-943-4375 563-773-2345 Info@lamotte-telco.com