AUTHORIZATION AGREEMENT FOR PRE-AUTHORIZED PAYMENTS

For 2016/17 School Year
* Denotes Required Fields

IF YOU CANNOT COMPLETE ALL REQUIRED FIELDS CONTACT THE ADMINISTRATIVE OFFICE AT 518-477-4125

* I (we) hereby authorize Greenbush Child Caring, Inc. to initiate a debit entry to my (our) CHOOSE ONE

indicated below and the depository named below, hereinafter called Depository, to debit same to such account.

*The ABA Number is the first nine digits listed on the bottom of your check.
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check

* One Account Holder Name Is Required

Please deduct the following dollar amount from my account monthly (between the 20th – 25th day of each month beginning,

/20/

This authority is to remain in full force and effect until Greenbush Child Caring, Inc. and Depository have received written notification from me (or either one of us) of its termination in such time and in such manner as to afford Greenbush Child Caring, Inc. and Depository a reasonable opportunity to act on it.

If there are two names on the account, both account holder signatures are required

*

By signing and electronically submitting this ACH form you are agreeing to ACH amounts changing if you increase or decrease enrollment

Greenbush Child Caring Inc. Info

Greenbush Child Caring, Inc.
620 Columbia Turnpike
East Greenbush, NY 12061

Phone (518) 477-4125
Fax (518) 479-4240
E-mail contactus@gbccinc.org