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AHC Authorization Form
The undersigned (“Customer”) hereby authorizes Attentive Home Care to initiate debit entries and to initiate, if necessary, credit entries and adjustments for any excess debit entries or debit entries made in error, to Customer’s account indicated below and the depository named below, to debit and/or credit the same such accounts. This authority is to remain in full force and effect until terminated by mutual agreement of the parties.
Customer Name
Customer Address
Depository Information
Financial Institution Name
Financial Institution Address
City/State/Zip
Telephone Number
Routing Number
Account Number
Signed by
Signature
Name
Date
MM slash DD slash YYYY
Please send a voided check via mail to:
Attentive Home Care
, 680 Commerce Drive #270, Woodbury, MN 55125 or Or Fax to : (612) 568-9977
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