Recurring Payment Authorization Form


Recurring Payment Authorization Form
Schedule your payment to be automatically deducted from your bank account or charged to your Visa or MasterCard.
Complete and sign this form and fax back to 206-350-6811 or mail to: 8685 SE 47
St, Mercer Island, WA 98040
Recurring Payments Will Make Your Life Easier:
It’s convenient (saving you time and postage)
Your payment is always on time (even if you’re out of town), eliminating collection calls
Here’s How Recurring Payments Work:
You authorize regularly scheduled payments to be made from your checking/savings account or charges to your
credit card. You will automatically be charged the amount indicated below each billing period. You agree that no
prior-notification will be provided.
Please complete the information below:
I (we) __________________________ authorize Congregation Shevet Achim to Debit my Checking/Savings
(full name)
Account or Charge my Credit Card indicated below for $________ on or around the 10
calendar day of each
month for payment of my Dues, Security Fee and/or Building Pledges. I (we) understand this does not cover other
miscellaneous pledges or donations made throughout the year.
Apply this amount to: ____________________________________________________________________________________
ACH Debit Bank Account
Credit Card
Charge to
Name on Acct
Credit Card #
Bank Name
Exp. Date
Account Number _________________________
Security Code
Bank Routing #
Cardholder Name ____________________________
Bank City/State
Billing Address
City, State, Zip
Please attach a voided check (recommended)
Convenience fee applies
No fees to use this service
I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Congregation Shevet Achim in writing of any changes in my account
information or termination of this authorization at least 15 days prior to the next billing date. For ACH debits to my checking/savings account, I understand that because
these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH
Transaction being rejected for Non Sufficient Funds (NSF) I understand that Congregation Shevet Achim may at its discretion attempt to process the charge again within
30 days, and agree to an additional $25 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I
acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit
card/bank account and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated
in this authorization form.


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Parent category: Business