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Electronic Funds Bank Transfer Authorization

I (we) authorize Latchkey Child Services, (called "CENTER" in this Authorization) to initiate debit entries to my (our) Checking or Savings Account indicated below at the depository financial institution indicated below (called "DEPOSITORY" in this Authorizations). I (we) authorize CENTER to withdraw sufficient funds to pay my (our) regular childcare tuition and/or other childcare related fees that are due and payable. I (we) authorize CENTER to use the third party sender, Tuition Express* to process all payments. I (we) acknowledge that the origination of Automated Clearing House (ACH) transactions to my (our account must comply with the provision of United States Law.

Credit Union Members: Please contact your Credit Union to verify account and routing numbers for automatic payments.

Client Information


Client Number, if known: (Optional)
Name on Check:
(or Savings)
Phone #:
(Ex: XXX-XXX-XXXX)
Street Address
City:
State:
Zip: (Ex: XXXXX or XXXXX-XXXX)

Bank Information


Bank Name:
Bank Street Address:
Bank City:
Bank State:
Bank Zip: (Ex: XXXXX or XXXXX-XXXX)
Select Account Type: Checking
Savings
Routing Number: 9 Digits
Account Number:
Include leading zeros (Ex: 0001234567)
Tuition Express is normally processed on the first school day of each week. If you require special processing, such as once a month, or other specific processing requirements, please list your request in the field below. Special processing will result in a payment processing fee of $9.95 per payment. If we cannot accommodate your specific request, we will contact you by telephone.
Special Instructions:

Signature


This authorization will remain in full force and effect until I (we) notify the CENTER in writing of its termination in such time and in such manner as to afford Tuition Express and DEPOSITORY a reasonable opportunity to act upon it. Notices must be received at a minimum of 5 business days in advance of the termination date.

Please review your entries for accuracy before submitting.
BY ENTERING YOUR NAME YOU ARE DIGITALLY SIGNING THIS FORM.
Please enter your full name and current date in the fields below.
Electronic Signature:
Date: MM/DD/YYYY
Record Retention Notice: The child care provider shall retain all parent (client) authorization forms in a secure location for a period of two years from the date of client withdrawal from the Tuition Express program.

 


Corporate office: 1141 N. Robinson, Suite 404, Oklahoma City, OK 73103 / (405) 236-2069 / (405) 236-3909 fax