Credit Management and Counseling Services, Inc.

PO Box 480

Sicklerville, NJ 08081

Phone. 877.684.2735

Fax. 215.754.4480

Direct Debit sm
DEBIT AUTHORIZATION FORM

PLEASE DEBIT MY:

CHECKING ACCOUNT

SAVINGS ACCOUNT

Customer Name(s) ________________________ ID Number (SS#) __________________

Beginning Debit Date ______/______/______

Deducted Thereafter: ______Weekly _______ Bi-Weekly______ Monthly______ Semi-Monthly(1st & 15th)

Please place voided check here

PLEASE PRINT ALL THE NUMBERS THAT APPEAR ACROSS THE BOTTOM OF YOUR CHECK

CHECK NUMBER AS IT APPEARS ON THE VOIDED CHECK ABOVE

Name of Bank	________________________________________________________
Bank Address	________________________________________________________
Phone #	________________________________________________________

Client Signature (s) _____________________________________ Date ______________

Please note: Any changes or cancellations concerning the EFT must be submitted in writing to our office three business days prior to the existing debit date. If notice is not given within the specified period of time, your account may be debited. Payments returned for insufficient funds may be charged a fee of $20.

Rev.6/10/03