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vgpayments.docx - Louisiana State Police

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					                         LOUISIANA GAMING CONTROL BOARD
                   DEPARTMENT OF PUBLIC SAFETY AND CORRECTIONS
                                 GAMING AUDIT SECTION
                          7919 INDEPENDENCE BLVD (BOX A-17)
                                 BATON ROUGE, LA 70806

          AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS

Licensed Device Owner:

License Number:

E-mail Address:


I hereby authorize the Louisiana State Police, Gaming Enforcement Division, hereinafter called
“Division”, to initiate debit entries and to initiate, if necessary, credit entries and adjustments for my debit
entries in error to my (select one)            Checking          Savings Account indicated below and the
financial institution named below, hereinafter called “Financial Institution”, to debit and/or credit the
same to such account.
Financial Institution Name:
Branch:                                                  Account No.:

Address:
City:                                                    State:                        Zip Code:

This authority is to remain in full force and effect until the Division has received written notification from
me of its termination in such time and in such manner as to afford the Division and Financial Institution a
reasonable opportunity to act on it.
Name:                                                           Name:
                         (please print or tape)                                        (please print or tape)

Signature:                                                      Signature:

Date:                                                           Date:


           TO BE COMPLETED BY THE PARTICIPATING FINANCIAL INSTITUTION

Is the Above Account Number correct?               Yes         No   Correct Number:
Participate in Automated Clearing House (ACH)?                          Yes            No
Financial Institution’s Transit/ABA Number:

Authorized Officer:                                                           Title:
                                      (please print or tape)

Signature:                                                                    Date:




DPSSP 0038 rev 11/2009

				
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posted:1/12/2011
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