After School Program Authorization for recurring direct payment

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

  • 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:

  • 9 digits
  • 4-17 digits
    This amount will be debited on the 15th day of each month, beginning 9/15/20
  • Date Format: MM slash DD slash YYYY
  • Accepted file types: jpg, gif, png, pdf.
    Please upload a photo of a voided check or document from bank.