Recurring Autodraft Payment Authorization (ACH)

Recurring Autodraft Payment Authorization (ACH)

By signing this form, I (we) give Revelation Community Management, Inc. permission to debit my (our) Checking Account for association assessments on or about the 5th of the month in which they are due. These assessments include recurring assessments and special assessments. I (we) have indicated the account for which the funds should be withdrawn below and agree that no prior-notification will be provided for this draft to occur.
Name:*

First NameLast Name
Community Name:*
Property Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have a different mailing address? If Yes, please include below.*
Mailing Address (if different from the property address):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is this a change to your current ACH bank information?*
Bank Name:*
Checking Account Number:*
Routing Number:*
Did an employee encourage you to sign up for ACH?
If so, who?
Please Initial: I understand that new draft requests, changes or cancellations of the draft must be received by the 15th day of the current month to take effect the following month. *
Please Initial: I understand that previous balances due will not be drafted and that if there is currently an unpaid balance on my account, I should submit a one-time payment through the website portal or by mail. *
Please Initial: In the case the transaction is returned by my (our) bank for any reason, including but not limited to insufficient funds or closed account, Revelation Community Management may discontinue the draft and charge fees for any returned items. *
All written debit authorizations must provide that the receiver may revoke the authorization only by notifying the originator in the manner specified in the authorization.

Both parties agree to be bound by the NACHA Operating Rules as they pertain to this transaction. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law.

I certify that I am an authorized user of the bank account as stated above and that I have the authority to authorize this payment on the account's behalf.
Phone Number:*
Please enter a valid phone number.
Email Address:*
example@example.com
Confirm Email Address:*
example@example.com
Signature:*
Date:*

MonthDayYear
Date
Once your form is submitted, you will receive an email confirmation of receipt of the request.
Should be Empty: