PA Dutch ACH Form 1

User Manual: PA-Dutch-ACH-Form-1

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The Pennsylvania Dutch Council, BSA
Direct Payment Option
The Pennsylvania Dutch Council is pleased to offer you a new service - The Direct Payment Option. Now you can have your
Friends of Scouting payment deducted automatically from your checking account on a monthly or quarterly basis.
What are the advantages of The Direct Payment Option:
• It saves time – no need to remember to write the check and put it in the mail.
• It saves postage
• It helps the Pennsylvania Dutch Council minimize monthly billing costs
• It’s easy to sign up for, easy to cancel.
Here’s how the Direct Payment Option works:
You authorize regularly scheduled payments to be made from your checking account using the form below. Your donation
payments will be made automatically on the 15th of the month and proof of payment will appear on your bank statement.
The authority you give to charge your account will remain in effect until you notify us in writing to terminate the
authorization.
All you need to do is:
• Indicate whether your payment will be deducted from your checking account monthly or quarterly.
• Fill in the amount to be debited, your name, financial institution name and location, and today’s date.
• Attach a voided check for verification of all financial institution information. If you are unable to attach a voided check,
please fill in your bank account number and routing number.

Note: Be sure to sign the form!
Please complete the information below.
-------------------------------------------------------------------------------------------------------------------------------

I authorize the Pennsylvania Dutch Council, BSA to initiate electronic debit entries to my Checking Account for
payment of my Friends of Scouting pledge:

□ Monthly

□ Quarterly

Amount to be debited: $___________
Monthly debits will be done on the 15th of each month
Quarterly debits will be done on the 15th of the first month of each quarter. (Jan., April, July, Sept.)

I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. This
authority will remain in effect until I have cancelled it in writing.
Date ___________________
FINANCIAL INSTITUTION NAME (PLEASE PRINT) _____________________________________________
FINANCIAL INSTITUTION ROUTING NUMBER _______________________________________________
ACCOUNT NUMBER AT FINANCIAL INSTITUTION ____________________________________________
FINANCIAL INSTITUTION CITY AND STATE __________________________________________________
SIGNATURE __________________________________________________________________________

Please sign and attach a voided check and return to:
Pennsylvania Dutch Council, 630 Janet Ave, Lancaster PA 17601
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