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.

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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)

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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

Visa

MasterCard

Checking

Savings

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

____________________________

Phone#

____________________________

Email

____________________________

Please attach a voided check (recommended)

Convenience fee applies

No fees to use this service

SIGNATURE

DATE

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.