Account Key _____________________________ (Office Use Only)

Automatic Withdrawal/Payment Form for Thunder Hawk Care ______________________________________________________________________________________________________ Parent/Guardian Name Phone # ______________________________________________________________________________________________________ Address City State Zip Child(ren)’s Names: _________________________________________________________________________________

There are two ways to set up a payment plan for Thunder Hawk Care! We are excited to offer the safety, convenience and ease of Tuition Express® — a payment processing system that allows secure, on-time tuition and fee payments to be made from either your bank account or credit card. You can provide credit/debit card information to the Community Education Office and the bi-weekly payment (including current tuition due and all other fees/charges) will be deducted from your account - or - you can have the bi-weekly payment deducted from your bank account (either checking or savings).

ELECTRONIC FUNDS TRANSFER AUTHORIZATION FOR BANK ACCOUNT and CREDIT CARD I (we) hereby authorize Montevideo Community Education to initiate credit card charges to my (our) credit card account OR, initiate debit entries to my (our) checking or savings account, indicated below (Section B). This authority will remain in effect for the 2016-2017 school fiscal year. To properly affect the cancellation of this agreement, I (we) are required to give 10 days’ written notice. _____ (initial) ______________________________________________________________________________________________________

COMPLETE ONE SECTION ONLY SECTION A (Credit Card) Credit Cards Accepted: Visa & MasterCard. If you choose the credit/debit card method, you must give your card information personally or over the phone to the Community Education office at (320) 269-5026. (Credit/Debit card information cannot be retained on paper by the Community Education office.)

SECTION B (Bank Account) *Please attach a voided check.

__________________________________________________________________________________________________ Bank or Credit Union Name

Bank or Credit Union Address

City

State

Zip

__________________________________________________________________________________________________ Routing Transit Number (see sample below)

Account Number (see sample below)

 Checking

 Savings

______________________________________________________________________________________________________ Authorized Signature Date