Direct Payment Form

Your Title *

Your First Name *

Your Last Name *

Your Email *

Are you entering the information to receive or make payments?

Account Information

Name(s) on Bank Account *

Account Number *

Routing Number *

Name of Your Bank *

Amount, Date & Purpose

If you are opting for the two-installment (Sept 7 and Jan 15) or the four-installment option (Sept 7, Nov 15, Jan 15 and Mar 15), please submit one form for each payment date.

Amount to debit in USD: *

Debit the earliest on *

Month

Day

Year

Debit the latest on *

Month

Day

Year

Please enter the amount and a date range. Accounting will process the debit within the date range, not earlier not later, but usually close to the earliest date indicated. If the date entered falls onto a weekend or a bank holiday, the direct debit will be processed the latest on the next following business day.

Purpose *

Please enter the first name(s) of the student(s) that this payment is for and which category or categories this payment is for (e.g. tuition, annual books & materials contribution, etc.).

Confirmations *

Please read the Direct Debit Terms & Conditions before checking the authorization checkboxes below. All are required.

By signing and submitting this form I authorize My French Classes to debit my account by the amount above within the indicated time period.

Authorization *

I acknowledge that a non‐sufficient funds fee of $25 will be charged by My French Classes in the event there are insufficient funds available on the account at the time the ACH direct debit is submitted.

Authorization *

I herewith confirm that I have read the Direct Debit Terms & Conditions.

Signature *

Please write your first and last name to certify your direct debit authorization. By signing you certify that you are an authorized signor on the bank account indicated above.

Optional Message

Please enter any message or question for accounting you may have in the box above.