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srg-ach-form

SRG ACH Payment Form

Date (Required)

Vendor Name (Required)

Vendor Name (Required)

Remittance Advice Email Address (Required)

Remittance Advice Email Address (Required)

Fed Tax ID# (Required)

Fed Tax ID# (Required)

BANK Name (Required)

BANK Name (Required)

BANK Account # (Required)

BANK Account # (Required)

BANK Routing Number (Required)

BANK Routing Number (Required)

BANK Account Type (Required)

Checking

Savings

By submitting this form you authorize Serenitee to originate transfers via Electronic Funds Transfer (EFT) and confirm that you are an authorized signer on the provided account.

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