HHS Stadium ACH Pledge Authorization Form

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Hampshire County Board of Education
HHS Stadium Note Sinking Fund
c/o Denise Hott, Finance Director
111 School Street
Romney, WV 26757

This form is used to collect the information to set up the ACH pledge authorization to collect donations to curtail the debt obligation created for the purpose of the stadium renovation for the benefit of the community.

Sample rendering of the stadium renovation

First Name *

Last Name *

Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

I (we) pledge the following amount to be paid and continued monthly. *

$10

$20

Other

If other, please specify the amount to be paid and continued monthly.

Process ACH on this day of each month *

I (we) will make this contribution in the form of an ACH electronic debit from my checking account.

Routing Number (Valid Routing # must start with 0, 1, 2 or 3) *

Account Number *

Bank Name

Would you like to be recognized for your donation (e.g. Listed as a donor in The Hampshire Review) *

Yes

Recurring ACH Pledge Agreement

I hereby authorize my bank to debit my account as identified to the terms stated here. This authorization shall remain in effect until Hampshire County Board of Education receives notification from me of intent to terminate at such time and in such manner as to afford Hampshire County Board of Education reasonable opportunity to act (minimum 30 days).

All other changes such as payment amount, frequency, bank account number change, will require a new ACH Debit Payment Authorization Form to be filled out and submitted to Hampshire County Board of Education 15 days prior to any change being implemented. I understand that this payment plan may be cancelled by Hampshire County Board of Education due to NSF (Non-sufficient Funds). Donations into this account are specifically to curtail the debt obligation created for the purpose of stadium renovation for the benefit of the community.

If you have any questions regarding the ACH process or making a donation, please contact either Trey Stewart (304) 822-7250 or Denise Hott (304) 822-3528 x133.

I represent and warrant that I am authorized to execute this payment authorization for the purpose of implementing this donation plan. I indemnify and hold the Service Provider, the bank, and Hampshire County Board of Education harmless from damage, loss or claim resulting from all authorized actions hereunder:

Electronic Signature *

Date *

YYYY

Submit

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