Bank Account Verification Form

To avoid processing delays, please ensure that the name, address, account number and signature on your submitted documents are clearly legible.

Client Information

General Information

Your Name: eCash Account Number:

Banking Information

Bank Name: Bank Routing/Transit Number: Bank Account Number:

Indicate the type of Bank Account:

Checking Savings

IMPORTANT: Please read the following carefully before signing and dating.

Terms of Agreement

When you request a deposit or payout by Instant Check, you are requesting a payment transfer to or from your personal bank account.

You agree that such requests, by internet or by telephone, will constitute your authorization for such transfers.

Withdrawal requests cannot be processed until funds are received for all deposits made in your account.

You also agree that if any transfers into your eCash account from your bank account result in Non-Sufficient Funds (NSF), an NSF fee of $25 for each NSF item will be charged to your bank account and we may re-bill such transfers to your bank account. Additionally, at our sole discretion, we may request information from you to verify your personal bank account information. To ensure collection of funds, we may also forward documentation and a copy of this agreement to your bank or a designated collection agency. All delinquent accounts will be reported to the credit bureau.

Lastly, you agree that you have read and accepted the terms described in the Transaction Processing Agreement.

I hereby agree to the terms and conditions set forth in the above statement.

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