AUTOMATIC DEBIT PROGRAM

Application

I authorize FirstService Residential DC Metro, LLC, as managing agent for
_____________________________________________________________ (homeowners association), to automatically debit my
[    ] checking    [    ] savings account.

Application Type (please circle one):   New Application    or    Bank Change Only

Bank Routing # **
__________________________________________________________

Bank Account # **
__________________________________________________________

Financial Institution
__________________________________________________________

City
___________________________________


State
___________


Zip
___________

**Please note that with credit unions, information for automatic debit may be different from what is printed on the check or deposit ticket.

Staple voided check here

I understand that this authorization will be in effect until I notify my managing agent in writing that I no longer desire this service, allowing management reasonable time to act on my notification.  I also understand that if corrections in the debit amount are necessary, it may involve an adjustment (credit or debit) to my account. I acknowledge that the transaction will occur during the first week of each month the Assessment is due. I also understand that there is a service charge per payment returned, for any reason.  If two payments are returned within one year, the service will be stopped and I will be responsible for making payments on balances due. 

THIS AUTHORIZATION IS NONNEGOTIABLE AND NONTRANSFERABLE.

Association Name
__________________________________________________________

Property Address (for payment to be applied)
__________________________________________________________

Assessment Account Number
__________________________________________________________

Payor’s Name & Email
__________________________________________________________

Payor is (please circle one):    Owner    Renter    Other: ________________________________

Phone Number
__________________________________________________________

The Automatic Debit Form must be received before the 15^th of the month to start the draft the following month. You will receive a confirmation letter notifying you when your first automatic debit will occur.  You are responsible for sending payments up until such time as you are notified in writing that your first payment will be taken out of your account.