ACH Form

Name*
First Last
Email*
Business Name
Service Address*
Street Address Address Line 2 City State ZIP Code
Phone*
IGL Account Number
Automatic Payment from Checking or Savings Account
Financial Institution*
City/State*
Name(s) on Acct*
Bank Routing #*
Bank Acct #*
Checking or Savings*
- Checking
- Savings
Acknowledgement*
- I hereby authorize IGL TeleConnect, until such time as I may cancel this arrangement in writing, to withdraw funds from the account or credit card listed above for the payment of each monthly bill on the date that it is due

Automatic Payment from Checking or Savings Account