Latchkey Child Services: Where Students Get to Be Kids

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.

Acknowledgement*

I agree to the above.

Client Information

Client Number, If Known

Name on Account*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Bank Information

Bank Name*

Bank Address*

Street Address Address Line 2 City State ZIP Code

Select Account Type*

Checkings

Savings

9-Digit Routing Number*

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. This will result in a payment processing fee of $9.95 per payment. If we cannot accommodate your specific request, we will contact you by phone.

Special Instructions

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 five business days in advance of the termination date.

Please enter your full name and current date in the fields below to sign this form.

Signature*

Date*

Record Retention Notice: The childcare 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.

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Tuition Express – Bank Account

Electronic Funds Bank Transfer Authorization

Client Information

Bank Information

Want to pay with your credit or debit card?

Latchkey Child Services Inc.