Direct Deposit

First name *

Last name *

Email address *

Effective date * +

Name of financial institution *

Routing number *

Account number *

Account type *

Savings

Checking

Authorization

Authorization *

I authorize Assigned Counsel Program to initiate credit entries to the account indicated above for the purpose of expense. I also authorize Assigned Counsel Program to initiate, if necessary, debit entries and adjustments for any credit entries made in error.

Signature *

clear