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��American Planning Association Muking Great Communities Happen Direct Debit Option: Membership installment payment by electronic withdrawals five (5) easy installments! WHAT? If your invoice billing includes renewal for an APA membership and you are an individual, you qualify to have your dues payments and all other services on this invoice spread over up to 5 easy installments electronically. W ithdrawals can be drawn from your savings or checking account. Qualifications: ❑ Billed for APA membership renewal ❑ You are an individual member paying your own APA membership dues [Agencies paying employees membership dues do not qualify for this service] ❑ W ithdrawal is made from a US Bank account with US dollars. WHY? Because it is automatic and convenient for our members! Because it is a FREE benefit to our members! HOW� STEPS TO CHOOSE THIS NEW DIRECT DEBIT OPTION: 1) APA must receive this Direct Debit selection no later than January 20th. 2) Complete form below and attach a VOIDED blank check. 3) Commencement of this service will be determined based on DATE RECEIVED BY APA. 4) This service will terminate with the 2nd month of your service period. E.g. if your service period is from April 1st to March 31 st, the 2nd month of your service period is May. 5) Equal installments will be made on the 29th of the month; the number of installments will vary based on date received by APA. E.g. if you miss the deadline you can still enroll in the program if this form is received by the 20th of the following month after the original deadline, the payments will be withdrawn in 4 installments instead of 5. The scheduled date may have to be changed in order to fall on the first business day prior to the date specified. The final installment may be less than previous installments. 6) There is no fee to cancel this direct debit service; cancellations must be submitted in writing. 7) NSF payments will result in removal from program. 8) There will be NO REFUNDS for withdrawals already made by the direct debit option. 9) There can be no additions or exchanges to this direct debit option once the renewal notice has been submitted. AUTHORIZATION AGREEMENT FOR PRE-ARRANGED PAYMENTS (Direct ACH Debits) I hereby authorize the American Planning Association, hereinafter called COMPANY to initiate debit entries to my checking or savings account as indicated below and the bank named below, hereinafter call DEPOSITORY, to debit the same to such account. Depository: Name of Bank: Branch: City: State: Zip: TransiUABA No: Bank Account No: (Bank routing number) Account type: [ ] Checking [ ] Savings This authority is to remain in full force and effect for one billing cycle and must be reauthorized each year. I have the right to cancel a direct debit entry by written notification to Depository and Company at such time as to afford Depository and Company a reasonable opportunity to act on it prior to charging account. I understand I will be invoiced for any unpaid dues. I understand that there are no refunds for withdrawals already made. After account has been charged, I have the right to have the amount of an erroneous debit immediately credited to my account by the Depository, provided I send written notice of such debit entry in error to the Depository within 15 days following issuance of the account statement or 45 days after posting, whichever occurs first. Name: APA ID #: Signature: Daytime Phone #: [] Voided check attachecj..� [] Renewal invoice notice attachet� ;� 165517 146 145•2 January