Document

AUTHORIZATION FORM

DIRECT DEBIT OF ACCOUNT

Name: _________________________________________________________________________________________________

Last First Middle

SSN#: (Optional) ____________________________

Primary Phone Number: _____________________Secondary Phone Number: ________________________

Property Address: ___________________________________________________________________________________

Email Address: _______________________________________________________________________________________

Please check an option below (select only one):

_____Automatic Debit - recurring debit from a checking or savings account. Please complete and sign this form, attach a voided check for the account you wish to debit Phone number is required.

_____Change of accounts and/or financial institution. Please complete and sign this form, attach a voided check for the account you wish to debit. Phone number is required.

____Cancel participation. Please complete and sign this form, for the account you wish to remove from participation. Phone number is required.

Financial Institution:_______________________________________________________________________________

City: ____________________State: ______________________Zip: ___________________

Select Primary Account: _____Checking* _____Savings*

Account Number #______________________________________

Routing Number # ______________________________________

Your routing and checking account numbers appear at the bottom of your check. To assure accuracy, please attach a voided check.

If you have trouble locating these numbers, please contact your financial institution for assistance.

The amount due on your monthly rent payment is automatically deducted from your banking account for each billing period, unless written authorization is received canceling participation of direct debit. OGI will notify you of any changes to the rate.

*Please be advised that, if you choose to use a Savings...