Wire Authorization Form - Ben Franklin Technology Partners

Wire Authorization Form

I, the Customer named below, hereby authorize Ben Franklin Technology Partners of Southeastern Pennsylvania (“Ben Franklin” or the “Company”) to initiate a wire to my or savings account at the financial institution listed below (the “Financial Institution”).

This authorization will remain in effect until I notify Ben Franklin in writing (by mail to the attention of Cynthia Banaszak at Building 100 Innovation Center, 4801 South Broad Street, Suite 200, The Navy Yard, Philadelphia, Pennsylvania 19112; with a copy of such notice by contemporaneous email to cynthia@sep.benfranklin.org that I wish to revoke this authorization in such time as to afford Ben Franklin and the Financial Institution reasonable opportunity to act on my request. I understand that Ben Franklin requires at least ten (10) business days’ prior written notice in order to cancel this authorization.

First Name*

Last Name*

Company Name*

Street Address*

City*

State*

Zip Code*

Owner

Finanical Institution Information:

Bank Name*

Account Number*

Routing Number*

Customer Authorization:

I hereby (a) certify that the information provided on this form is complete and correct, (b) acknowledge and agree that I am solely responsible for any fees, charges or other costs relating to this authorization or the transactions made pursuant hereto, (c) authorize Ben Franklin Technology Partners of Southeastern Pennsylvania to electronically deposit payments to checking or savings account designated above and (d) acknowledge and agree that Ben Franklin Technology Partners of Southeastern Pennsylvania, by accepting or otherwise acting on this authorization, does not guarantee or warrant, nor is a guarantor or surety for, any payments due me, the Customer.

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Full Name *

Date *

Full Name *

Date *