Harbour Credit Counseling Services, Inc.
P.O. Box 9228
Virginia Beach, VA 23450
(757) 340-2564 Fax (757) 498-6432
Toll Free (800) 4-0-DEBTS
Toll Free Fax (800) 256-3504

AUTOMATIC CHECKING AUTHORIZATION

I hereby request and authorize the following Automatic Checking Authorization made with Harbour Credit Counseling Services Inc.:

Client Name(s):___________________________________

SSN:_______ - _____ - ________

Address:__________________________________________________________________________

City:_____________________      State:________  Zip:___________ Telephone:(_____)______ - _______

  Please (Check One) : Debit my  ____ Checking Account     ____ Savings Account

  A current, unsigned, voided check MUST be attached in the box below in order to process.

 

Attach Voided Check Here

 

We (I) have selected the Automatic Checking Debit option and authorize Harbour Credit to withdraw or "debit" the monthly amount of $_______from the above bank account starting the month of _____________.  Please check one:

(  ) Please withdraw on the 2nd

(  ) Please withdraw on the 16th

(  ) Please withdraw on the 5th

(  ) Please withdraw on the 19th

(  ) Please withdraw on the 9th

(  ) Please withdraw on the 22nd

(  ) Please withdraw on the 12th

(  ) Please withdraw on the 26th

Termination from Automatic Checking:
Harbour Credit Counseling Services Inc. will terminate or change debits from our (my) bank account only upon our (my) written request at least 7 days prior to the next scheduled debit date. We (I) acknowledge that if Harbour Credit Counseling Services Inc. does not receive that notice in the allotted time, Harbour Credit Counseling Services Inc. cannot guarantee  that the Total Monthly Amount will not be debited from our (my) account. Furthermore, due to Harbour Credit Counseling Services's Non-Profit status, Harbour will not be responsible for overdraft fees caused by automatic debits. Funds debited from our (my) bank account and all other payments made to Harbour Credit Counseling Services Inc. for payment of the Listed debts will not be returned to us (me) at any time for any purpose. However, funds will be paid to the creditors on the Creditors List to pay or reduce our (my) Listed Debts.
Insufficient Funds:
In the event of insufficient funds the client agrees to immediately submit a money order for the monthly payment plus a $25.00 NSF charge.  Automatic checking will continue the following month.
Holding Period:
We (I) acknowledge that Harbour Credit Counseling Services Inc. is required to hold all automated checking payments for 3 business days before disbursing to my (our) listed debtors.

Client Signature_____________________________________ Date:_______________

A Licensed Non Profit Agency
www.40Debts.org