Online ACH Form

ACH Debits or Paper Drafts

I authorize you, MENDOCINO COMMUNITY NETWORK (“MCN”), to initiate ACH Debits or Paper Drafts ("Debit Entries") to my deposit account ("Account") at my Financial Institution named below. This authorization is for the payment of recurring monthly amounts I owe MCN for Internet Services.
IN ORDER TO TERMINATE OR REVOKE THIS AUTHORIZATION, I MUST NOTIFY MCN, THE ORIGINATING COMPANY, IN WRITING.
So long as this authorization has not been terminated or revoked, any Debit Entry originated by MCN, under this authorization shall be conclusively presumed to be properly payable against my MCN Account.
I CAN STOP PAYMENT OF ANY SINGLE DEBIT ENTRY BY NOTIFYING MCN OR MY FINANCIAL INSTITUTION THREE (3) DAYS BEFORE MY DEPOSIT ACCOUNT IS CHARGED.
I understand that if there are insufficient funds in my Account when any authorized Debit Entry is presented, my Financial Institution may, at its discretion, pay or refuse to pay the Debit Entry, and may apply its usual returned check fees and charges. MCN may also charge a bounce payment fee. I also understand that if my Financial Institution refuses to accept a Debit Entry for any reason, MCN will not reprocess it without further reauthorization from me.
I authorize my Financial Institution to charge these Debit Entries to my Account upon receipt and without advice to me.

My Financial Institution Name *

Street Address OR Branch *

City, State, Zip *

Routing Number *

Account Number *

Name on Account *

Authorized Debit Entries

MCN is authorized to originate Debit Entries to my Account to pay recurring amounts I owe you in the FIRST WEEK of the month for Fusion customers and 15th of the month for all other customers. The amount of these recurring payments may vary; however, no Debit Entry in any month may exceed the current amount owed to MCN. All notices and advices will be sent to the email address on my MCN account. I also authorize adjustment entries in the event of erroneous transactions to my account. I hereby certify that I am an owner and authorized signer of the Account. MCN may supply a copy of this Authorization Agreement to my Financial Institution or to MCN's Bank upon request.

Signature *

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Date

Voided Check *

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Print Name *

Are you a human? *

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Authorization Agreement for Direct Payments