ACH Remote Deposit Application


Customer Tax ID Number:

Company Name:

Primary Contact:

Email Address:

Telephone:

Physical Address:


Remote Deposit Information

Please take some time to fill out the below information regarding your deposits.

Maximum Deposit Amount
Maximum Check Amount
Average Number of Checks Per Deposit
Percentage of Returned Checks Per Month
Last 3 Digits of Accounts To Be Deposited Into
Acct1: Acct2: Acct3:

Please Enter Names Making Deposits
Place Check in Box If User is Account Signer

ACH Origination Information

Please take some time to fill out the below information regarding ACH Origination.

Maximum Origination Amount
Maximum Single Item Amount
Average Number Item Per Transaction
Average Transmission Amount
Frequency of ACH Transactions
Weekly      Bi-Weekly      Monthly      Bi-Monthly
Anticipated Start Date
Type of ACH Transactions
Payroll     Other
Credit      Debit

Please Enter Names of People Making Deposits
Place Check in Box If User is Account Signer