ACH Authorization

AUTHORIZATION AGREEMENT FOR PRE-AUTHORIZED PAYMENTS

* Denotes Required Fields

IF YOU CANNOT COMPLETE ALL REQUIRED FIELDS CONTACT THE ADMINISTRATIVE OFFICE AT 518-477-4125

Parent Last Name *

Parent First Name *

Enter your email address *

Child(ren) Last Name *

Child(ren) First Name *

I authorize Greenbush Child Caring, Inc. to initiate a recurring monthly ACH/electronic debit from my account in the amount of: *

from my checking or savings account between the 20th and the 28th of each month (Choose one). *

Checking

Savings

Name of Bank or Credit Union *

Address *

City/State/Zip *

ABA Number *

*The ABA Number is the first nine digits listed on the bottom of your check.

Re-Enter ABA Number *

Account Number *

Re-Enter Account Number *

Name of Account Holder 1 *

*One Account Holder Name Is Required

Name of Account Holder 2

I understand that this authorization will remain in full force and effect until I notify Greenbush Child Caring, Inc. in writing that I wish to revoke this authorization. I understand that Greenbush Child Caring, Inc. requires at least two weeks prior notice in order to cancel this authorization.

If there are two names on the account, both account holder signatures are required.

Account Holder Name *

Date *

By checking the box, you are signing electronically

Account Holder 2 Name

Date

By checking the box, you are signing electronically

By signing and electronically submitting this ACH form you are agreeing to monthly tuition payments being deducted and any additional amounts if you make a change to enrollment, have late payment, late pick-up fees or choose to add additional (single, full or half) days.

I agree that ACH transactions I authorize comply with applicable laws.

Name

ACH Authorization

Site Map

Greenbush Child Caring Inc. Info