First Protestant Church/School
Automatic Bank Withdrawal
Authorization Form
Date: ________________________
I/we ___________________________________________________ authorize First
Protestant Church to draft our bank account for our child/children’s tuition and/or
miscellaneous charges associated with First Protestant School.
Parent/Guardian Signature
Address:
______________________________________________________
______________________________________________________
Phone Number:
______________________________________________________
Email Address:
______________________________________________________
Printed Name:
______________________________________________________
(As it appears on your bank account)
Bank Name:
______________________________________________________
Bank Account #:
______________________________________________________
Bank Routing #:
______________________________________________________
Deduction Options:
(Please Check One)
_____ 1st of the month for total amount
_____ 1st & 15th of the month for 50/50 of amount due
*If this date falls on a weekend, the deduction will be made on the first working day
following that weekend.
OFFICE USE ONLY:
Child’s Name:
Child’s Class:
ACH Start Date:
ACH End Date:
_____________________________________
_____________________________________
_____________________________________
_____________________________________