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Name :

Address :

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Phone Numbers:

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Identification Number:

I. Financial Institusion

Name :

Address :

Phone Numbers:

Fax Number:

Bank Routing Number:

Account Number:

Type of Account:

Amount to Deposit:

             I authorize MARLENE BIRCH to deposit all payments due to me in the account(s) named herein. I further authorize MARLENE BIRCH the authority to make debits or take other corrective actions, if necessary, in relation to any deposit made by MARLENE BIRCH into the account(s)

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