Auto Withdrawal (ACH) Payment Change Authorization
Payer Full Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Please list the names of the student(s) whose accounts will be affected by this change:
*
*
I, the undersigned, request that the following banking information be used for ACH payments, as indicated below:
Payments to be changed (select all that apply)
*
K-12 tuition and fees
Child Care or Preschool tuition and fees
Donations and Pledges
Payment to be withdrawn on
*
1st (monthly)
15th (monthly)
Weekly (child care only)
One time only (please specify in Comments section below)
Comments
New Bank Name
*
New Bank Routing Number
*
New Bank Account Number
*
Type of Bank Account
*
Savings Account
Checking Account
Date this change takes affect
*
-
Month
-
Day
Year
Date Picker Icon
Today's date
*
-
Month
-
Day
Year
Date Picker Icon
Payer Signature
*
Submit
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