Direct Payment Form

Your Title *

Your First Name *

Your Last Name *

Your Email *

Are you entering the information to receive or make payments? *

Has your bank account information changed since you last submitted this form? *

If your bank information is not yet on file, e.g. if you are submitting this form for the first time, please select YES.

Account Information

The account has to be a CHECKING account. Savings or other accounts do not allow to process direct debits.

Name(s) on Bank Account *

Account Number *

Routing Number *

Name of Your Bank *

Amount, Date & Purpose

Below you can select a date range around the due dates based on your personal preferences. Please select a date range of about 5 business days.

Amount to debit in USD: *

Debit the earliest on *

Day

Month

Year

Debit the latest on *

Day

Month

Year

Please enter the amount and a date range. Please leave a date range of about 5 business days. Accounting will process the debit within the date range, not earlier not later, but usually close to the earliest date indicated. If the date entered falls onto a weekend or a bank holiday, the direct debit will be processed the latest on the next following business day.

Purpose *

Please enter the first name(s) of the student(s) that this payment is for and which category or categories this payment is for (e.g. tuition, annual books & materials contribution, summer camp, French Griffons Soccer etc.).

Credit Amount & Purpose

Please enter the amount you are requesting and the reason for the reimbursement below.

Amount to credit in USD: *

Purpose *

Please enter the first name(s) of the student(s) that this payment is for and which category or categories this payment is for (e.g. tuition, annual books & materials contribution, summer camp, French Griffons Soccer etc.).

Confirmations *

Please read the Direct Debit Terms & Conditions before checking the authorization checkboxes below. All are required.

By signing and submitting this form I authorize My French Classes to debit my account by the amount above within the indicated time period.

Authorization *

I acknowledge that a non‐sufficient funds fee of $25 will be charged by My French Classes in the event there are insufficient funds available on the account at the time the ACH direct debit is submitted.

Authorization *

I herewith confirm that I have read the Direct Debit Terms & Conditions.

Signature *

Please write your first and last name to certify your direct debit authorization. By signing you certify that you are an authorized signor on the bank account indicated above.

Optional Message

Please enter any message or question for accounting you may have in the box above.