Scribd
Upload
77 views1 page

Ach - Dda 0210

This document is a merchant services change request form for updating a merchant's bank account information for ACH debits and credits. It requires the merchant to provide their name, merchant number, old and new bank account information including routing and account numbers, and the signature of an authorized principal. The form must be faxed along with a voided check to the data processing department, and the request will not be processed until the required documents are received and approved.

Uploaded by

Alfonso Williams
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
77 views1 page

Ach - Dda 0210

This document is a merchant services change request form for updating a merchant's bank account information for ACH debits and credits. It requires the merchant to provide their name, merchant number, old and new bank account information including routing and account numbers, and the signature of an authorized principal. The form must be faxed along with a voided check to the data processing department, and the request will not be processed until the required documents are received and approved.

Uploaded by

Alfonso Williams
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 1

Merchant Services

BANK ACCOUNT NUMBER FOR ACH DEBITS/CREDITS


CHANGE REQUEST FORM
IMPORTANT - PLEASE READ BEFORE PROCEEDING:
ALL INFORMATION LISTED IS REQUIRED AND MUST BE COMPLETED.
PLEASE FAX THIS REQUEST FORM AND A VOIDED CHECK TO
DATA PROCESSING AT (818) 540-6712.
THIS REQUEST WILL NOT BE EFFECTIVE UNTIL THE REQUIRED
DOCUMENTS ARE PROVIDED AND APPROVED.
Thank you for your cooperation.
Merchant Name: ____________________________________________________________
Merchant Number: __________________________________________________________
IMPORTANT: If the merchant name on the check is different than the current name
on the merchant account, the request will not be processed without a completed Business
Name Change form. Please contact Merchant Services at (800) 554-2777 or via email to
[email protected] for a copy of this form.
Old Banking Information:
_______________________________

______________________________________

_____________________________________
Transit Routing Number / ABA Number

______________________________________________
Account Number

Bank Name

Bank Phone Number

New Banking Information: (Must be a checking account)


_______________________________

______________________________________

_____________________________________
Transit Routing Number / ABA Number

______________________________________________
Account Number

Bank Name

Bank Phone Number

___________________________________________________
Signature of Authorized Principal

_____________________
Date

(as specified on the Merchant Application/Agreement)

_____________________________
Print Name

________________
Phone

____________________________
Email Address

If you should have any questions, please contact our Merchant Services department at (800) 554-2777 or email us at
[email protected]

A $25.00 processing fee will be charged to the new checking account.

Revision Date: Feb 2010


04 IPI ACH_DDA 0210

You might also like