AUTHORIZATION AGREEMENT FOR AUTOMATIC DEBIT FROM CHECKING OR SAVINGS by ban11070

VIEWS: 22 PAGES: 1

									                                                               Office Use Only
                                                               Pmt. start date ___________
                                                               Confirm letter sent ________
                                                               Receipt ________________
                                                               Session ________________

                     AUTHORIZATION AGREEMENT
                     FOR AUTOMATIC DEBIT FROM
                   CHECKING OR SAVINGS ACCOUNT
                      SCHOOL AGE CHILD CARE
For your convenience, you can have your Adventure Club monthly tuition automatically
debited from your checking or savings account. If you want to participate, please
complete the information below and return this form to:
                        SACC
                        3100 NE 83rd Street, Suite 2300
                        Kansas City, Missouri 64119

Please print clearly.

Name ________________________________________________________________
Address ______________________________________________________________
Child(ren)’s Name ______________________________________________________
Adventure Club Site _____________________________________________________
Do you need a monthly receipt?       ___ Yes   ___ No

I hereby AUTHORIZE the School Age Child Care program to withdrawal my
monthly tuition from my Checking or Savings account named below.

Date to be withdrawn (circle one):                      1st                  15th

Type of account (circle one):                        Checking              Savings

Bank Name ____________________________________________________________

Transit/ABA # _____________________________ Account # ____________________




                         ATTACH VOIDED CHECK HERE



The authority given is to remain in full force and effect until the School Age Child Care
program has received written notification from me of its change.

Signature _______________________________            Date ________________________

								
To top