Bank Authorization Form for Kumon Math and Reading Center of Westchester

I hereby authorize you to debit my account as identified above. This authorization shall remain in effect until the terms stated have been met or until Kumon of Westchester has received written/e-mail notification from me of intent to terminate at such time and in such manner as to afford Kumon of Westchester and bank reasonable opportunity to act (minimum of 15 days). All other changes such as payment amount, frequency, bank account number change, will require a new Payment Authorization Form to be filled out and submitted to Kumon of Westchester 15 days prior to any change being implemented. I understand that this payment plan may be cancelled by Kumon of Westchester due to uncollectible funds. I will be liable to pay a fee for each returned check. I understand that if my electronic debit is returned to you for insufficient or “held” funds, it will be re-presented electronically and my account will be debited for the amount of the payment plus the state-allowed fee. I understand that any fees charged according to Westchester Kumon’s policies (e.g., late payment fee, check returned/insufficient funds fee, etc.) will be automatically added to the above monthly payment during the month the fee is assessed. I represent and warrant that I am authorized to execute this payment authorization for the purpose of implementing this payment plan. I indemnify and hold Kumon of Westchester, the check processor, and the bank harmless from damage, loss, or claim resulting from all authorized actions hereunder.