Authorization for Debit & Credit Electronic Funds Transfers
COMPANY: NATIONAL STAR SERVICES / TELEPHONE: (630)595-6396Last Name: | First Name: | M.I.: Social Security Number: | Location: | Company:
I hereby authorize on my employer and/or third party as referred to here within, and their agents including Intercept Corporation (IC), to initiate electronic withdrawals and/or deposits to the bank account shown below. I understand that adjustment and/or reversing entries may be made to this account to insure an accurate and balanced accounting of all transactions. This authorization will remain in effect until; a) I notify my Bank and IC in writing to terminate this agreement and give the Bank and IC reasonable time to terminate this agreement.; b) The Bank, third party/employer, and/or IC’s have sent me five business days advance written notice of the Bank’s and/or ICs termination of this Agreement.
I understand that any cancellation in writing will be effective no earlier than five (5) business days after the day the last transaction has cleared and there are no outstanding balances to the account.
I UNDERSTAND THAT INTERCEPT CORPORATION PROVIDES ELECTRONIC FUND TRANSFER SERVICES TO THIRD PARTIES AND/OR MY EMPLOYER. THE FUNDS TO BE TRANSFERRED MUST BE COLLATERALLY FUNDED AND ARE FULLY GUARANTEED BY MY EMPLOYER AND/OR MYSELF. IN THE EVENT THE FUNDING FOR A TRANSFER IS RETURNED FOR ANY REASON OR INTERCEPT HAS BEEN PROVIDED INCORRECT INFORMATION AND/OR HAS ERRONEOUSLY TRANSFERRED FUNDS TO MY ACCOUNT, I AUTHORIZE INTERCEPT CORPORATION TO WITHDRAW/REVERSE FROM MY ACCOUNT THE AMOUNT OF FUNDS TRANSFERRED IN ERROR. I ALSO UNDERSTAND THAT IC MAY WITHDRAW AND/OR DEPOSIT TO MY ACCOUNT VARIOUS FUNDS REGARDING MY PARTICIPATION IN A FLEXIBLE BENEFIT/CAFETERIA PLAN/ERISA PLAN. I HEREBY HOLD INTERCEPT EFT AND EMPLOYER HARMLESS FOR TRANSFERRING ANY FUNDS DESIGNATED FOR FLEX BENEFITS UPON THE DIRECTION OF MY EMPLOYER OR PROCESSOR, AND THAT MY REMEDY FOR ANY ERRONEOUS TRANSFERS IS SOLELY AGAINST THE PROCESSOR AND THAT I WILL HOLD HARMLESS INTERCEPT EFT FROM ANY LIABILITY AND DAMAGES RESULTING THEREFROM. I UNDERSTAND, AGREE AND ACKNOWLEDGE THAT AS PART OF THE ACH PROCESS, ONCE FUNDS ARE DEBITED FROM THE BANK ACCOUNT SHOWN BELOW PURSUANT TO THIS AGREEMENT, SUCH FUNDS SHALL BE PLACED IN ONE OR MORE IC ACCOUNTS AT ICS BANK AND THAT IC SHALL BE THE ONLY ENTITY AUTHORIZED ON SUCH ACCOUNTS. I FURTHER ACKNOWLEDGE THAT SUCH IC ACCOUNTS SHALL BE SUBJECT TO SETOFF BY IC’S BANK.
Electronic Funds Transfers (15 U.S.C 1693): I hereby acknowledge receipt of notice by the financial institution described here within of(i) the undersigned’s liability for an unauthorized electronic fund transfer, (ii) the undersigned’s duty to promptly report such unauthorized transfers, (iii) the undersigned’s liability for charges for electronic fund transfers. (iv) the undersigned’s right to stop payment of pre-authorized electronic fund transfers, (v) the procedure to initiate such stop payment orders, (vi) the right to receive documentation of electronic fund transfers, and (vii) the Bank’s liability pursuant to Electronic Funds Transfer Act found at 15 U.S.C 1693 el al.
Limitation of Action: I acknowledge that I have 60 days from the date of a withdrawal from or deposit to the account shown below to dispute the withdrawal or deposit by contacting my employer and Intercept Corporation by telephone and later supplemented in writing, or in writing of any discrepancies, errors or disputes concerning any transfer of funds to or from any account processed by Intercept. This will include but not limited to, errors in amounts, erroneous transactions, or other transactions processed. All written notices must include the following information:
The name of the company with whom the undersigned authorized the transaction, i.e, employer and/or third party; Federal Taxpayer ID number of the company authorized to make the transaction; Federal Taxpayer ID number of the undersigned;The name of the undersigned; The name, account number and ABA number on the transaction in question; The dollar amount of the transaction in question; and Description of the error and explanation of the error.
I understand and agree that my employer, its agent, or IC will inform me of the results of their investigation within ten (10) days of the receipt of the complaint and will correct any errors promptly. I understand and agree that if my employer, and/or its agent, or IC need more time, IC may take up to 45 days to investigate the undersigned’s complaint. For transfers initiated outside of the United States or transfers resulting from point of sale or debit/access cards, the time periods for resolving errors will be 45 days and 90 days, respectively.
YOUR PAYMENT OPTION SELECTION:
EMPLOYEE DIRECT DEPOSIT INFORMATION (if applicable)
Account #: | ABA/Routing #:
Bank Name: | Address & Telephone:
Upload of ACH form from employee bank:
Upload of voided check:
EMPLOYEE PAYCARD INFORMATION (if applicable)
Paycard #: | ABA/Routing #: 073972181
Bank Name: Meta Bank | Address & Telephone: 5501 S. Broadband Lane Sioux Falls SD 57108
By providing the information requested above and signing below, I hereby elect and consent to receive my wages, including but not limited to off cycle wage payments and wage payments upon discharge, by electronic transfer of wages to a paycard. In addition, to the extent permitted by applicable law, I hereby authorize my employer to make all of my deposits and deposit adjustments, including those involving off cycle wage payments and wage payments upon discharge, to my paycard, and I authorize the bank where such funds are deposited to accept such deposits and make such adjustments. I acknowledge I have received a copy of the terms, conditions, and fees associated with using such paycard. This authorization shall remain in effect until fourteen (14) days after my employer receives written notice from me terminating my authorization.
PAYSTUBS AND W-2s
Employee elects to receive electronic paystubs:
Employee elects to receive electronic W-2s:
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Authorization for Debit & Credit Electronic Funds Transfers
Agree & Sign