CSA ACH Form Peninsula ACHForm

User Manual: PeninsulaACHForm

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Peninsula Security Systems, Inc.

590 West 9th Street
San Pedro, Ca 90731
(310) 514-3144 Fax (310) 832-6769
peninsulasecurity.net

AUTOMATIC CHECKING ACCOUNT WITHDRAWL ENROLLMENT FORM
(Please print or type)

CLIENT NAME

ALARM ACCOUNT NUMBER

CLIENT ADDRESS
ZIP

CITY

STATE

HOME TELEPHONE

CELL TELEPHONE

EMAIL ADDRESS

If we receive your form by the 10th of the month before your cycle starts, ACH will begin on the 1st day of the next billing cycle.
For example, we would need your form by March 10th for an April-June cycle
2. The amount charged to your ACH will be the amount customarily billed on your account.
3. Payments will be charged on the 1st business day of each quarter/year.
4. If you would like to confirm your ACH start date, please contact us at (310) 514-3144
Cancellation and Change Policy
1. If you want to cancel ACH billing, please notify our office in writing no later than 7 business days before the 1st of the month for
which you want it cancelled.
2. If you need to change bank information on file for billing, please fax or mail this form with new account numbers and other
needed information, and a brief note of your request. Our fax number is (310) 832-6769.
3. Your request must arrive in our office no later than 7 business days before the 1st of the month for which you want it changed.
1.

Please contact us if you have questions about your participation in the Peninsula Security Systems ACH payment program.

SIGNATURE:____________________________ PRINTED NAME:___________________________DATE:________
I hereby authorize Peninsula Security Systems, Inc. to automatically pay my account charges via ACH payment until written
notification to discontinue. I have read and understand the above ACH Cancellation and Change Policy.

ATTACH VOIDED CHECK HERE
(Make sure bank codes are inside of the box)

Special Notes:
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