Ymca Loudoun County Form (Page 4 of 4) in pdf

EFT PAYMENT AUTORIZATION

YMCA of Metropolitan Washington

PLEASE ACKNOWLEDGE THE PAYMENT DATES BELOW:

Electronic Funds Transfer Monthly (on approximately the 10

Please choose method of payment in the

box below and provide all requested information.

Thank you for selecting EFT payment option. Your payments will be drafted once a month on approximately

the 10

of the month. See schedule below for approximate monthly draft dates. Please refer to the

informational guidelines below for making any changes to the EFT process or contact.

Draft Dates:

August 10

September 10

October 10

November 10

December 10

January 10

February 10

March 10

April 10

May 10

PLEASE COMPLETE PAYMENT AUGHORIZATION BELOW

(Please Check Method of Payment)

CREDIT CARD AUTHORIZATION

DRAFTS WILL OCCUR ON APPROXIMATELY THE 10

OF EACH MONTH

INITIALS_________

I authorize the YMCA to charge my credit card for child care payments. I understand that I must provide written notice of cancellation. If at any time there is to be a

change, deletion, or cancellation of my child’s child care enrollment, it is to be submitted in writing to the YMCA branch where child care was purchased two weeks

prior to the date of my credit card draft in order to discontinue the debit.

_______________________________

___________

AMEX

VISA

DISCOVER

NAME AS IT APPEARS ON CARD

CARD ISSUER

______________________________________________

_________

________________________________

CREDIT CARD NUMBER

EXP. DATE

SIGNATURE OF CARD HOLDER

BILLING ADDRESS OF CARDHOLDER: ______________________________________________________________________________

CITY: ________________________________________ STATE: _______ ____ZIP:_________________

BANK DRAFT AUTHORIZATION

DRAFTS WILL OCCUR ON APPROXIMATELY THE 10THOF EACH MONTH

INITIALS________

I authorize my bank to honor pre-authorized drafts drawn by the YMCA on my account for child care payments. I understand that my EFT drafts will occur automatically

until I provide written notice to the YMCA two weeks prior to the date of my bank draft payment. When the bank honors the draft by charging my account, such drafts

constitute my receipt for the payment. Should any draft not be honored by said bank when received by them, it is understood that the payment is to be made by me in

the amount of said payment, plus a service charge. If at any time there is to be a change, deletion, or cancellation of my child’s child care enrollment, it is to be

submitted in writing to the YMCA branch where child care was purchased two weeks prior to the date of my draft in order to discontinue the debit. A voided check is

required with all electronic funds transfer (EFT) applications.

_____________________________________

________________________________

___________________________

NAME OF BANK

ACCOUNT NUMBER

TRANSIT/ROUTING NO.

_____________________________________

________________________________

____________________

PLEASE PRINT NAME

SIGNATURE OF ACCT. HOLDER