Eft Payment Authorization Form printable pdf download

EFT P a y m e n t A u t h o r i z a t i o n F o r m

Hood Residences

. THE HOOD PLANT 191 So Winooski Ave #10 Burlington, VT 05401

TEL: 802-860-7068

FAX: 802-860-1414

in conjunction with Merchants Bank College St. Burlington, VT 05401

Itʼs Convenient! The system is safe and reliable, and your rights with Automatic Bill Payments are protected by State

and Federal regulations. How Does it Work? Once your automatic payments have started, you just note the date and

amount in your checkbook. How Do I Sign Up? Complete and mail the below Automatic Bill Payment Authorization

Form. Start enjoying the safety, convenience and savings of this alternative method of paying bills! Any questions,

please call 802-860-7068 or email

For my monthly rental payments: __________________________. I (we) hereby authorize The Hood Residences

to initiate debit entries to my (our) account indicated below and the Merchants Bank to debit the same from such

account periodically for scheduled monthly payments as they become due. I (we) hereby authorize The Hood

Residences to initiate the debit on the 1st day of the month throughout the lease term.

How Preauthorized Debits Work. The transfer date will be the 2nd of the month. The preauthorized charge will be

attempted on the transfer date. Funds must be available for withdrawal on the transfer date. If the transfer date is a

non-business day the transfer will be processed on the NEXT business day. If the debit is returned by the Financial

Institution, the transfer will be attempted again. This will occur until funds are available or The Hood Residences

terminates this agreement. The Hood Residences may terminate this agreement if any 3 debit entries are returned by

the Financial Institution. If a payment is not made before the grace period expires, a LATE CHARGE will be assessed

and the next preauthorized debit will include late charges and include multiple payments, for which you will not receive

special notification.

Fill in the following account information for the

Notice: A voided sample check or deposit slip must accompany

financial institution from which funds will be

this form.

debited.

Check one: [ ] _________________

Checking Account #

Name

010

[ ] _________________

Street

Savings Account #

City/State/Zip

_________20____

___________________

EXAMPLE CHECK:

Bank Routing Number

______________________________________

Pay to the order of_____________________

Financial Institution (holding deposit account)

$$ _______________________Dollars

______________________________________

For ____________________________

Address

_____________________________

_________________________________________

:010101010: 1010909090:

010

City

State

Zip

Routing # A ccount # C heck #

Mail completed authorization form and “Voided Check” or deposit slip to:

The Hood Residences THE HOOD PLANT 187 So Winooski Ave Burlington, VT 05401 FAX: 802-860-1414

This authority is to remain in full force and effect until The Hood Residences has received written notification from me

(or either of us) if its termination in such time and in such manner as to afford The Hood Residences and Merchants

Bank a reasonable opportunity to act on it. I (we) have read, understand, and agree to the terms stated.

Signature ______________________________

Printed Name ____________________________ Date_____________

Address:________________________________________________________________________

Tel. # __________________________ Cell #________________ E-Mail _______________________

Eft Payment Authorization Form

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