Fillable Auto Association (Ach) Payment Authorization Form printable pdf download

Auto Association (ACH) Payment Authorization

For use by Condo/Homeowner Association members that remit Association dues payments to

Regions Bank only.

The most convenient way to make your Association payments. Simply complete the bottom portion of this form with

the requested information, attach a void check, and your Association payments will be automatically drafted from

your deposit account.

Important Information:

•

You must verify with your Association that ACH Payments are accepted. Any Authorization forms received that have not

been approved by the Association or Property Manager will be returned. This could cause your Association payment to

be delayed.

•

By returning the Authorization form below, you will authorize your Association to collect your payments automatically,

saving you time and money.

•

Association payments are debited on the 5

day of each month. (Note: If the 5

day of the month falls on a weekend or

holiday, the debit will be processed on the next business day.)

•

Authorization forms must be received by the 15

day of the current month in order to be in effect for the next month’s

regularly scheduled payment.

•

Payments can only be drafted from U.S. bank or credit union accounts titled in the name of the property (unit) owner.

•

If multiple payments are made for this property (unit), a separate authorization form must be submitted for each payment.

(For example, a regular monthly payment and a separate garbage payment paid with different coupons).

•

Simply complete the form below with all required information and return along with a voided check to:

Association Lockbox Services P.O. Box 11407 – Dept. 6000 Birmingham, AL 35246-6000

Unit/Property Owner Record

Association Name: ____________________ Unit No.: __________________

Address: ______________________________________________________

CSZ: _________________________________________________________

Name of Debiting Financial Institution: _______________________________

Debiting Account No. ____________________________________________

Routing/Transit Number from Check: ________________________________

Date Submitted: ___/___/_____

Auto Association (ACH) Payment Authorization

Complete and return with a voided check to address shown on the Authorization Coupon

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Auto Association (ACH) Payment Authorization

Condo/Homeowner Association: _______________________________

Unit No.__________________

Property Owner Name: _______________________________________

Street Address: ______________________________________________

Phone No. ________________

City: ___________________

State/Province: _____________

Zip/Postal Code: ____________

Name of Financial Institution: ______________________________

Phone No. _________________

Bank Routing/Transit No.: ___________________ Bank Account No. :______________________

Bank Account Type: ___ Checking ___ Savings A Voided Check Must Be Attached

I authorize Condo/Homeowner Association to initiate debit entries to the account named above at the depository financial institution named above for the purpose of making

my association payments. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. This authorization is to

remain in full force and effect until Condo/Homeowner Association has received written notification from me of my termination of this authorization . Authorization forms

must be received by the 15

day of the current month in order to be in effect for the next month’s payment.

_______________________________________________

__________________________________

Unit Owner Signature

Date

Mail To: Association Lockbox Services P.O. Box 11407 Dept. 6000 Birmingham, AL 35246-6000

Incomplete Forms or Forms without Voided Checks will be returned to your Association or Property Management Company and

may cause your Association payment to be delayed.