Payment Plan Authorization Form-Leesburg Montessori Payment Plan Authorization Form-Leesburg Montessori Parents NameDate of Birth (father) Date Format: MM slash DD slash YYYY Date of Birth (mother) Date Format: MM slash DD slash YYYY Address Street Address City State Zip Code Social Security Number (father)Social Security Number (mother)Payment Plan ScheduleTotal Tuition Amount $Number of InstallmentsSelect OneOne-time PaymentRecurring Debit (every month)Payment Amount $Payment Date (MM/DD/YYYY) Date Format: MM slash DD slash YYYY Start Date (MM/DD/YYYY) Date Format: MM slash DD slash YYYY End Date (MM/DD/YYYY) Date Format: MM slash DD slash YYYY A voided check from customer's bank account must be uploaded here. Drop files here or Payment AuthorizationI authorize my bank to debit my account as identified above to the terms stated here. This authorization shall remain in effect until the Service Provider and bank receive written notification from me of intent to terminate at such time and in such manner as to afford the Service Provider and bank reasonable opportunity to act (Minimum 30 days). I understand that if the total amount owed to the Service Provider is increased, I authorize this plan to continue as long as the payment amount remains unchanged until the amount owed the Service Provider is paid off, or unless the plan is terminated earlier by me as above. I understand any added amounts can be applied for with a new ACH Debit Authorization Form. All other changes such as payment amount, frequency, bank account number change, will require a new ACH Debit Payment Authorization Form to be filled out and submitted to Merchant 15 days prior to any change being implemented. I understand that this payment plan may be cancelled by the Service Provider or Merchant due to NSF (Non-sufficient Funds). I will be liable to pay an NSF fee of $50.00 (or the amount allowable by law), which may be automatically debited for each NSF. I represent and warrant that I am authorized to execute this payment authorization for the purpose of implementing this payment plan. I indemnify and hold the Service Provider, the bank, and Merchant harmless from damage, loss or claim resulting from all authorized actions hereunder.Customer SignatureDate Date Format: MM slash DD slash YYYY
