Tuition/ach Payment Agreement Form printable pdf download

QUEEN OF ALL SAINTS SCHOOL

TUITION/ACH PAYMENT AGREEMENT

I authorize Queen of All Saints School to establish an automatic payment from my bank account in

accordance with the terms listed under ‘payment schedule’ until the tuition balance is paid in full.

I agree that all payments may be made automatically from my bank account as per the terms listed

under “payment schedule” of this agreement. I authorize payments to continue as per the total

payment amount listed under “payment schedule” until the total charges are paid in full.

To change an existing agreement, a “QAS Change of Status Form” needs to be completed by the

of the month for the change to go into effect on the 15th.

I understand after two (2) months of non-sufficient payments my automatic withdrawal will be

cancelled and my payments of cash only will be made directly to the school office.

FAMILY INFORMATION

Family Name _________________________Address ______________________________

City, State ________________________ Zip _______ Phone _______________________

Student(s) Name ____________________________________________________________

PAYMENT INFORMATION

Balance Due _________ Total # of Payments______ Amount of Each Payment

_________

BANK INFORMATION

PAYER INFORMATION

Name of Institution

_______________________

Name of Payer: _______________________

City, State _______________________________

Account Type: Savings ____ Checking _____

Payer Signature ___________________________

Routing # __ __ __ __ __ __ __ __ __

Date __________

Account # ____________________________

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Day of Month for Payments: The 15

of each month, unless it should fall on a Saturday, then the

Automatic withdrawal will be scheduled for the next business day.

First Tuition Payment for 10 month contract is 8/15/2016

Last Tuition Payment is 05/15/2017

*****************************************************************************************************************

PLEASE ATTACH VOIDED CHECK

= =============================================================================

FOR OFFICE USE ONLY

Received by_____________________ Verified by _______________________

Date _____

PDS ID _____________ Different Payer ___ Entered by_____________ Date_____________

Tuition/ach Payment Agreement Form