ACH Form

Authorization for recurring direct payment (ACH Debits)

Please list the name of each child participating in the Boys & Girls Clubs of Lanier After School Program
Child 1*
Child 2
Child 3
Child 4
Club Site*
Account Holder Name*
First Last
Account Holder Address*
Street Address City State ZIP Code
Account Holder Phone*
In consideration of the service provided to me by the Boys & Girls Clubs of Lanier, and as a duly authorized signer, I hereby authorize the Boys & Girls Clubs of Lanier to initiate a recurring debit entry to the checking account listed below at the Financial Institution listed below:
Bank Name*
Routing Number*
9 digits
Checking Account Number*
4-17 digits
Amount Debited per month:*
- One Child = $91.66
- Two Children = $183.32
- Three Children = $274.98
- Four Children = $366.64
This amount will be debited on the 15th day of each month, beginning 9/15/20
Authorization Agreement*
I consent to the Authorization Agreement
This authorization is to remain in full force and effect from August 1, 2020 to May 30, 2021. I may only revoke this authorization by contacting Boys & Girls Clubs of Lanier directly. Furthermore, if any such electronic debit(s) should be returned, unpaid (non-sufficient or uncollected funds), by the financial institution above, the account holder will be responsible for paying any incurred return item fees (per electronic debit) or the maximum amount allowed by state law.
Name*
First Last
Date*
Date Format: MM slash DD slash YYYY
REQUIRED: Void Check or Document from Bank*
Accepted file types: jpg, gif, png, pdf.
Please upload a photo of a voided check or document from bank.