I hereby authorize the Wisconsin State Lodge, Fraternal Order of Police, to initiate ACH debit entries to our bank account for the purpose of paying State and National Lodge Per Capita.
I confirm that our account will only be debited upon explicit authorization from a lodge officer specifying the date and the number of members for whom the per capita fees are to be paid. This authorization is contingent upon the receipt of such notice detailing the charges to be applied.
First Half Per Capita payment and $25.00 Yearly Admin Fee is due November 1st and Last Half Per Capita is due May 1st. Supplements are added throughout the year as members are added.
I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the Wisconsin State Lodge, Fraternal Order of Police in writing of any changes in my account information or termination of this authorization. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF), I understand that the Wisconsin State Lodge, Fraternal Order of Police may, at its discretion, attempt to process the charge again within 30 days and agree to an additional $25 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this bank account and will not dispute these scheduled transactions with my bank; SO long as the transactions correspond to the terms indicated in this authorization form.