Thank you for choosing the ACH monthly payment plan! Please fill out this form completely and legibly. Your payments will be withdrawn on the 10th of each month (September-April) or the Monday after, if date falls on a weekend. The first payment will include both September or your first month of class, PLUS the last month of classes (May). Proof of payment will appear on your bank statement.

    ACH Monthly Withdrawal Authorization

    RESPONSIBILE PARTY

    AUTOMATIC BANK PAYMENT INFO
    PAYMENT TERMS 
    The first payment will include both September or your first month of class, PLUS the last month of classes (May). The remaining payments will be divided among the rest of the classes (typically 7 additional months– Oct, Nov, Dec, Jan, Feb, Mar, Apr). One month notice from the first of the month is required to discontinue any class. To withdrawal, you must inform the front desk staff AND complete a withdrawal form provided by the front desk. We DO NOT refund the last month payment. Please visit our website or ask at the front office if you have questions about this or would like to see an example. You agree that no prior-notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected.
     
    I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Village Dance Studio in writing of any changes in my account information or termination of this authorization at least one month prior to the next billing date. If the above noted periodic payment dates fall on a weekend or holiday, I understand that the payment may be executed on the next business day. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that Village Dance Studio may at its discretion attempt to process the charge again within 30 days, and agree to an additional $20 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I agree not to dispute this recurring billing with my bank so long as the transactions correspond to the terms indicated in this authorization form.

6290 Central Blvd, Whitestown, IN 46075    |    317.769.2223    |    [email protected]