ACH Debit Form

Membership Dues Payment by Direct Debit
ACH Debit Form

Only available for funds held in a U. S. Bank in U. S. Dollars

Why?

Because it's convenient and automatic.
Because it spreads your dues balance over 10 easy installments.
Because it's a free benefit to you.

How?

Complete and send this form with a voided check or bank specification letter to Congregation Rodeph Sholom. Do not send a deposit slip. Dues payment by direct debit is only an option for Full and Associate members.
Monthly installments equal to 1/10 of your total dues balance will be deducted from your account on the 20th of each month--if this form is received after your membership period's beginning date, the monthly installment will be calculated on the number of months remaining in the membership year.
This direct debit arrangement will be in effect for one year only.

Authorization Agreement for Pre-Arranged Payments (ACH Debits)
VOIDED CHECK (faxed or original) or bank specification letter is REQUIRED to begin process.

I (we) hereby authorize Congregation Rodeph Sholom to initiate debit entries to my (our) checking or savings account as indicated below, and authorize the depository named below to debit the same to such account.

Bank Information - Account Type

SavingsChecking

Account Holder's Name

Transit/ABA Number (9 digit bank routing number)

Account Number

Please read carefully and sign below.
This authority is to remain in full force and effect for one year. I have the right to have the amount of an erroneous debit immediately credited to my account by Congregation Rodeph Sholom, provided I (we) send written notice of such debit entry in error to Rodeph within 15 days following issuance of the account statement or 45 days after posting, whichever occurs first. I (or either of us) have the right to stop payment of a debit entry by written notification to Rodeph at such time as to afford Rodeph a reasonable opportunity to act on it prior to charging account. I understand I will be invoiced for any unpaid dues. I further understand that there may be a $35.00 fee for all insufficient funds, direct debit returns for accounts closed without notification.

Member's Name (if different from account holder)

Phone Number

Membership ID

Account Holder's Signature

Date signed

** DON'T FORGET TO INCLUDE A VOIDED CHECK **

Thu, December 4 2025 14 Kislev 5786