Direct Payment via Bank ACH Consumer Authorization

I authorize United Childcare and Preschool of Sioux Falls, SD to electronically debit my bank account (and if necessary, electronically credit my account to correct erroneous debits). I agree that ACH transactions authorized by me comply with all applicable laws.

Please check one:

Checking Account

Savings Account

Bank or Credit Union Name:

Routing Number

Account Number

This debit will occur once a week on Monday.

I understand that this authorization will remain in full force and effect until I notify United Childcare and Preschool by calling 605.332.5940 that I wish to revoke this authorization. I understand that United Childcare and Preschool requires at least one week prior notice to cancel this authorization.

Child(rens) Name(s)

Date

YYYY

ELECTRONIC SIGNATURE

Name of account holder

First Name

Last Name

Direct Payment via Bank ACH Consumer Authorization

Connect with us!

United Childcare and Preschool is supported by Sioux Empire United Way, First United Methodist Church, and Asbury United Methodist Church.