Form Type(Required)

Vendor/Payee Information

Vendor / Payee Name(Required)
Vendor Address(Required)
Your deposit confirmation will be sent via email

Financial Institution Information

Branch Address(Required)
Type of Account:(Required)
Type of Account:(Required)
Approvals/Authorizations - I certify that the information provided on this form is correct, and I hereby authorize La Mesa Fund Control and Escrow to electronically deposit payments to the bank account designated above. It is my responsibility to notify LMFCE (infoap@lmfce.com or (619) 644-8500) immediately if I believe there is a discrepancy between the amount deposited to my bank account and the amount of the invoice(s) paid. I understand that I must notify LMFCE in writing immediately of any changes in status or banking information. I understand that this authorization will remain in full force and effect until LMFCE has received written notification requesting a change or cancellation and has had reasonable opportunity to act on it. Brokerage accounts or money market funds may not be able to recieve deposits via ACH. Deposits returned by your bank, due to incorrect information provided by you, will result in a $30 fee.
Name that will appear on Signature line in the ACH form
MM slash DD slash YYYY