Please complete a seperate inquiry for all company subsidiaries with separate Federal tax ID numbers. The asterik (*) indicates mandatory fields.
I (we) hereby authorize UPMC, herein called COMPANY, to initiate credit entries to my (our) which
is indicated below at the depository financial institution named below, hereafter called DEPOSITORY, and to credit the same to such account, I (we) acknowledge
that the organization of ACH transactions to my (our) account must comply with the provisions of the U.S. law.
This authorization is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its
termination in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.
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