Check Authorization Form
Customer Information
Arkansas Department of Transportation
Full Name: ________________________________________
P.O. Box: 2261
Address: ________________________________________
Little Rock
AR
72203-2261
City: ___________________
State: __________
ZIP Code: __________
(501) 569-2000
Phone Number: ________________________________________
Info@ar.gov
Email Address: ________________________________________
Bank Information
Bank of America
Bank Name: ________________________________________
P.O. box 27025 va2-430-01-01
Bank Address: ________________________________________
Richmond
VA
23261
City: ___________________
State: __________
ZIP Code: __________
061112788
Routing Number: ________________________________________
003359881060
Account Number: ________________________________________
Type of Account: - [ ] Checking
[ ] Savings
[ ] Business Checking
Transaction Details
401,912.50
Amount: $_______________________________
Transaction Type: - [ ] Charge
[ ] Refund
06/30/2024
Date of Authorization: _____________________
Effective Date of Transaction: _____________________
Authorization Statement
Lori H Tudor ARDOT Representative
I, ___________________________________
(Customer's Full Name),
Triump Trail Powerd by ACUSENSUS
authorize ___________________________________
(Merchant's Name) to initiate a single
electronic debit entry to my bank account indicated above for the amount specified. I understand that
this authorization will remain in effect until I revoke it in writing, and I agree to notify
Triump Trail Powerd by ACUSENSUS
___________________________________
(Merchant's Name) in writing of any changes in my
account information or termination of this authorization at least 15 days prior to the next billing date.
Customer's Signature: ___________________________________
06/30/2024
Date: _____________________