DIRECT DEBIT AUTHORIZATION FOR PARISH ACCOUNT #______________
I authorize Parish Communications and the financial institution listed below to initiate electronic debit entries and adjustments for any credit entries in error to my:
each monthly payment cycle. This authority will remain in effect until I have cancelled it in writing.
FINANCIAL INSTITUTION NAME (PLEASE PRINT)
ADDRESS OF INSTITUTION HOME ADDRESS
BRANCH PHONE NUMBER ACCOUNT NUMBER
CITY STATE SIGNATURE DATE
Financial Institution Routing Number _______________________
Date of withdrawal from account:
Would you like to continue receiving your monthly statement? _____Yes _____No
This authority is to remain in full force and effect until the Company of Customer has given notification of termination in such time and in such manner as to afford the Company and Financial Institution or Customer a reasonable opportunity to act on it.
Parish may charge a service fee for all returned checks, including, but not limited to, insufficient funds and closed accounts. The returned check amount (plus fee) must be replaced within three (3) business days of Parish notifying customer. Parish reserves the right to refuse automatic payments for a period of time following the return.
You will be charged a one-time set-up fee of $10 for this service. If you have any questions, please call our office.
Please attach a voided check to this form and send to our office:
P.O. Box 10
Auburn, MI 48611