FB ACH
Document Sample


Owens Corning/Fibreboard Asbestos Personal Injury Trust (FB)
ACH Debits
Law Firm Name: ____________________ Tax ID Number: ________________
I (we) hereby authorize Owens Corning/Fibreboard Asbestos Personal Injury Trust (FB),
hereinafter called COMPANY, to debit entries to my (our) ____ Checking Account/ ____
Savings Account (select one) indicated below at the depository financial institution
named below, hereafter called DEPOSITORY, and to debit the same to such account. I
(we) acknowledge that the origination of ACH transactions to my (our) account must
comply with the provisions of U.S. law.
Depository Name: _________________ Branch Name: ___________________
City: ____________________________ State: ____ Zip: _______________
ACH ABA Routing Numbe r: Account Number:
___________________________ _______________________________
This authorization is to remain in full force and effect until COMPANY has received
written notification from me (or either of us) of its termination in such time and in s uch
manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.
Name(s): ________________________ (FB) ID Number for Law Firm __________
Date: __________________________ Signature: __________________________
Authorized Signatory on about referenced
account
E-mail address of authorized person to receive payment notification:
________________________
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