I (We) hereby authorize Kansas District Court, Third Judicial District, herein after called COMPANY, to initiate debit entries to my (our) checking account indicated below for court costs only and the depository named below, herein after called DEPOSITORY, to debit the same to such account.
Depository Name _______________________________________ Branch _____________________________
City __________________________________ State ___________________ ZIP Code _________________
Transit/ABA No. __________________________________ Account No. _____________________________This authority is to remain in full force and effect until COMPANY and DEPOSITORY, has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.
Name(s) _______________________________________________ Tax ID Number _____________________ (Please print)
Date _________________ Signed x____________________________________________________________
Signed x____________________________________________________________