Electronic Funds Transfer Form printable pdf download

Electronic Funds Transfer Form

Parent’s Name: _________________________________________________________________

Parent’s Signature: ______________________________________________________________

Student’s Name: ________________________________________________________________

[__] Yes, please sign me up for EZ-EFT. Please fill out the authorization below.

[__] Continue my EZ-EFT, but please change the account information. Please fill out the authorization

below.

[__] Continue my EZ- EFT with the same account information as last year.

[__] Cancel my EZ-EFT from the prior school year. I will be paying by personal check for this school year.

If you need to add or change account information, please fill out the authorization below and attach a

voided check to the form and return it to the school office.

EZ-EFT Authorization

I hereby authorize ____________________________________________________to make my

(Name of your Financial Institution)

periodic payments on my behalf from the checking or savings account that is listed below and transfer it

to [School Name].

My EZ-EFT payments will begin on the 5

day of __________________, 20_____.

(Month)

Choose One:

[__] Checking Account Transfer: Account #_____________________________________

[__] Savings Account Transfer: Account #_____________________________________

I hereby understand that I am in complete control of my payment and if at anytime I decide to make any

changes or discontinue this service, I will notify the [School Name] and the change of payment method

will not affect the terms of my child’s enrollment.

_____________________________________________________________________________________

Signature

Date

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Electronic Funds Transfer Form