Central's Center for Children

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Central’s Center for Children Authorization Agreement for Automatic Drafts For the purpose of paying billed tuition and fees at Central Children’s Academy, I (We) do hereby authorize Central UMC, on behalf of Central Children’s Academy, to initiate debit entries and to initiate, if necessary, credit entries and adjustments for any debit entries in error to the account. I (We) also authorize the depository named below to debit and/or credit the same to such account.

Name of depository to be drafted: __________________________________________ City: ____________________________ State: ______ Zip Code: _________________ Transit ABA routing number: _____________________________________________ Account number: ________________________________________________________ Type of account: ______ Checking _______ Savings

Account will be drafted on the first (1st) or fifteen (15th) of each month. You may also choose to have ½ on the first and ½ on the fifteenth. Please indicate the date you prefer the account to be drafted. _____1st

_____15th

If the first or fifteen fall on a holiday or weekend, the account will be drafted on the next business day.

Accounts will be drafted each month in the amount billed for tuition and fees. This authority is to remain in full force and effect until such time as terminated by the executing party or the services of Central Children’s Academy cease to be used.

Name(s): (Please print) ____________________________________________________ Phone number: ___________________________ Start date: ______________________ Signature: ___________________________________ Date: ______________________ Signature: ___________________________________ Date: ______________________ Note: Please attach a VOIDED CHECK from the account(s) to be debited so that we may verify your bank’s Federal Reserve Transit ABA number for accurate processing.

02/28/12