Payment form

ASSOCIATION

(To be completed by Company)

HOMEOWNER ACCOUNT #

AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS(ACH DEBITS)

I (we) hereby authorize MTM Management, hereinafter called "Company," to initiate debit entries to my (our) Checking AccountSavings Account (select one) indicated below at the depository financial
institution named below, hereinafter called "Depository,” and to debit the same to such account for the purpose of collecting assessments for my community association.

I (we) understand that this debit will occur on or about the 15th of each month in which assessment payments are due. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of United States law.

Depository Name:

Bank Branch:

City:

State:

Zip:

Routing Number (9 digits):

Account Number:

This authorization is to remain in full force and effect until Company has received written notification from me (or either of us) of its termination in such time, and in such manner, as to afford Company and Depository areasonable opportunity to act on it. If you sell your property, please contact MTM to cancel this ACH.

Signature(s):

Email address:

Daytime phone:

Cell phone:

Start Month and Date

OK to charge past due balance with 1st draft: YesNo

NOTE: ATTACH A VOIDED CHECK FOR THE ACCOUNT THAT WILL BE DEBITED.If any payment is returned for any reason there is a $30 NON WAIVABLE FREE

Click here to attach

PLEASE NOTE: We must receive this form before the 5th os the month you would like ACH to begin. Form the 6th on, it will be processed the next month/quarter.

Payment form

AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS(ACH DEBITS)

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