Form F-Pas-312 - Automatic Tax Payment Information - Authorization Agreement printable pdf download

Saint Mary Nativity Catholic Church - 10566 - 01 • 2010 - 2011

F-PAS-312

Family Contact Information

Account Number (if previously enrolled with TMS): _____________________

Payer's Name:__________________________________________________________________________________

Mr. Mrs. Ms.

First

Middle Initial

Last

Payer's Date of Birth:_________/_________/_________ Family ID: _______________________________________________

Secondary Contact:_________________________________________________________________________________

Mr. Mrs. Ms.

First

Middle Initial

Last

Payer Street Address:_____________________________________________________________________ Apt: ________

City:__________________________________________________________ ST:___________ Zip:______________

Payer Telephone: (______)_________-_______________ Payer Email: _______________________________________ ___

Student 1:____________________________________________________________________________ Grade:_____

Student 2:____________________________________________________________________________ Grade:_____

Student 3:____________________________________________________________________________ Grade:_____

Student 4:____________________________________________________________________________ Grade:_____

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Envelope #:_______________

Parishioner at St. Mary Nativity

Parishioner at Holy Cross

Non-Parishioner

Plan Option:

12 Installments: $45

Due 6/1/2010 to 5/1/2011

PLEASE NOTE: EACH YEAR, YOU WILL BE AUTOMATICALLY REENROLLED AND INCUR THE APPLICABLE ENROLLMENT FEE FOR THIS PLAN UNTIL

GRADUATION OR CANCELLATION. ENROLLMENT FEES ARE SUBJECT TO CHANGE IN FUTURE ACADEMIC YEARS.

Enrollment Fee Payment Options:

For Enrollment Fee Amount, Refer to Section 2.



A check is enclosed for the enrollment fee. (Make check payable to Tuition Management Systems.)



Charge the enrollment fee to my credit card:

VISA

MasterCard

DISCOVER

American Express



Credit Card #:

Exp: _____ /20_____

Authorization Agreement for Automatic Payments

I hereby authorize Tuition Management Systems, a division of KeyBank National Association (“TMS”), to initiate debit entries to my account at the financial

institution indicated below for the amount due on my Monthly Payment Plan on the date the payment is due. All transfers will be made on the due date of

the payment or on the next processing day if the transfer date is a non-processing day for TMS.

TMS may, at its option, discontinue automatic funds transfers from the account if I fail to maintain sufficient funds in the account to cover the payments

required. This authority shall remain in full force and effect until TMS is notified by me by telephone or in writing to cancel it in such time as to afford TMS

and the Financial Institution a reasonable opportunity to act on it.

Checking/Statement Savings (circle account type) Account #:_____________________________________________________________________

ccccccccc

Financial Institution Routing #:

Financial Institution Name:____________________________________________

I will be notified by mail of the date the automatic payments will begin. Until that time, I will make payments by check or contact TMS for alternative

arrangements. I understand that is my responsibility to ensure that there are sufficient funds in the account to cover any debit authorized and to ensure that

payments are made on time.

PLEASE NOTE: EACH YEAR, YOU WILL BE AUTOMATICALLY REENROLLED AND INCUR THE APPLICABLE ENROLLMENT FEE AND

BANK WITHDRAWALS FOR THIS PLAN UNTIL GRADUATION OR CANCELLATION. ENROLLMENT FEES ARE SUBJECT TO CHANGE IN FUTURE ACADEMIC YEARS.

Payer Signature:

I hereby agree to any

_____________________________________ Date ____/____/20_______

and all information and agreements noted above:

Payer Signature

SCHOOL USE ONLY

1. Tuition

$____________.___

Notes: ______________________________________________________