Fillable Recreation Pass Electronic Transfer Agreement Form

3/28/2011

Troy Community Center

Recreation Pass Electronic Transfer Agreement

3179 Livernois, Troy, MI 48083 • 248.524.3484

Last Name on Account______________________________________ First Name________________________

Home Address______________________________________________________________________________

City_____________________ State_______ Zip Code____________ Daytime Phone____________________

Additional Pass Holder(s) using same EFT

account_________________________________________________

I hereby authorize the City of Troy and the designated financial institution to begin automatic deductions from

my account designated below in the amount of my monthly membership dues and fees:

Financial Institution ( Checking  Savings)________________________________________________

Transit/Routing Number____________________________ Account Number___________________________

Credit Card (Visa or Mastercard) Account ____________________________________ Exp Date__________

Terms of Electronic Transfer Agreement

 I understand that I am responsible for ensuring that the account designated above has sufficient available

funds on my automatic payment date to allow for the automatic deduction of payment for my pass and

any associated passes.

 I have attached a voided check to ensure the accuracy of the account number and transit/routing number

shown above if EFT are to be taken from my checking or savings account.

 I understand that the amount of the monthly deduction will be $_______________ unless I am notified

otherwise. The first EFT will take place on _______________.

 I understand that I must pay four months in advance at the time of processing my Recreation Pass.

 I understand installments will be taken from my account on/about the 15

of the month prior to the

upcoming month of recreational services (i.e. January 15

installment is for February usage).

 I understand that I will receive written notice in advance of any change in the date of my automatic

deduction, or any change in the amount due. I understand that automatic deductions will continue even

if there is a change in the date of the deductions or amount due for my membership, including the

renewal of that membership or the addition or removal of family members from my membership.

 I understand the City of Troy will suspend my Recreation Pass if it is unable to collect any payment due

and that I am liable for any uncollected payment and for any fees or penalties ($25 Service Fee) imposed

by the Troy Parks and Recreation Department.

 I am obligated for payment of the Recreation Pass(es) and any other outstanding fees related to it.

 This agreement will remain in effect until I have notified the Troy Parks and Recreation Department in

writing at least 30 days prior to my monthly installment date of any changes to my account or other

funded accounts that would prevent the monthly charge from being processed.

Signature_____________________________________________ Date_______________________________

HH Number:____________ Date Submitted:_____________ Amt Pd:_________ Existing EFT? Yes No

New Account Number: Yes No

Staff Initials_______

Recreation Pass Electronic Transfer Agreement Form - 2011