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FLORIDA INLAND NAVIGATION DISTRICT <br />ACH Authorization FORM <br />CREDIT/DEBIT AUTHORIZATION FORM <br />I (we) hereby authorize the Florida Inland Navigation District to initiate entries to my (our) <br />checking /savings account at the financial institution listed below, and if necessary, initiate <br />adjustments for any transactions credited/debited in error. This authority will remain in effect <br />until the Florida Inland Navigation District is notified by me (us) in writing to cancel it in such <br />time to afford the District and the financial institution a reasonable opportunity to act on it. <br />(Name of Financial Institution) <br />(Address of the Financial Institution -Branch, City, State, & Zip) <br />Signature <br />Name -PLEASE PRINT <br />Address -PLEASE PRINT <br />Financial Institution Routing Number: <br />Date <br />Name of Business/Agency <br />Checking/Savings Account Number: <br />These numbers are located on the bottom of your check as follows: <br />1:L234561: i:L23456789012118 <br />ROUTING NUMBER ACCOUNT NUMBER <br />