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LMA ACH FORM

Member ACH Form

This Agreement governs ACH transactions initiated by Livestock Marketing Association to credit or charge the Company indicated below. Both parties agree to be bound by NACHA Operating Rules as they pertain to all ACH transactions initiated by Livestock Marketing Association that credit or debit the Company bank account listed below, and acknowledge that the origination of ACH transactions to the listed account must comply with provisions of U.S. law.

You authorize charges to your checking/savings account. You will be charged the amount indicated below each billing period. A receipt for each payment will be emailed to you and the charge will appear on your bank statement as an “ACH Debit.” You agree that no prior-notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected.

Business Name

Which LMA Staff referred you to this form?

Payment to: Livestock Marketing Association

One Time PaymentRecurring PaymentPlease use this account for past due

Business/Individual Name on Bank Account *

Billing Address

Billing City *

State *

Zip *

Email *

Phone #

Ext

Bank Name *

Bank City/State *

Bank Account Number *

Verify Bank Account Number *

Bank Routing Number (9 digit #) *

Verify Bank Routing Number (9 digit #) *

Business bank account is enabled for ACH transactions?

YesNo

Please attach invoice (if applicable)CHOOSE FILE

I Authorize Livestock Marketing Association to initiate ACH Debits and Credits to the bank account indicated above, provided each transaction is initiated per the terms of this Agreement.

Signature

Signature (draw in the box below)

Printed Name

Title

Date

I certify that I am an authorized representative of the Company indicated above and that I have the authority to enter into this Agreement on the Company’s behalf. Company understands that this authorization will remain in effect until it is canceled in writing, and agrees to notify Livestock Marketing Association in writing at least 15 days in advance of any changes in its account information or termination of this authorization. Company understands that because these are electronic transactions, these funds may be withdrawn from its account as soon as the date an individual transaction is authorized, and that it will have limited time to report and dispute errors. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) Company understand that Livestock Marketing Association may at its discretion attempt to process the charge again within 30 days, and agrees to an additional $15 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized payment. Company has certified that the above business bank account is enabled for ACH transactions, and agrees to reimburse Livestock Marketing Association for all penalties and fees incurred as a result of Company’s bank rejecting ACH debits or credits as a result of the account not being properly configured for ACH transactions. Company acknowledges that the origination of ACH transactions to its account must comply with the provisions of U.S. law.