Debit Payment Plan Authorization for Glenwood Golf Corporation

Debit Payment Plan Authorization for Glenwood Golf Corporation

(Student Membership is excluded from this plan)

By arrangement with Glenwood State Bank, you have the option of paying our dues by setting up a monthly automatic deduction from your checking/savings account. You do not have to be a Glenwood State Bank customer to sign up for a payment plan. NOTE: We will not accept partial payments of dues unless they are handled through the method described herein. The bank will be instructed to deduct the funds from your account on the 5th day of the month. The funds deducted from your account will be deposited into the Glenwood Golf Course checking account. Don’t forget to deduct the amount from your checkbook each month.

Mail the completed authorization to: Glenwood Golf Course, Atten: Kay Eich, 57073 240th Street, Glenwood, IA 51534. To insure the payment to be deducted on time, the deadline for the completed form is the 25th of the month prior to starting your payment plan.

______Renewed Yearly Automatically

Month starting payment plan # of months Monthly Payment Ending Date

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Glenwood State Bank- Debit Authorization

I (we) hereby authorize (Glenwood Golf Corporation), herein after called COMPANY, to initiate debit entries to my (our) account indicated below and the financial institution named below, hereinafter called FINANCIAL INSTITUTION, to debit the same to such account for (Application). I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. Law.

Financial Institution Name Branch

Address City/State Zip

______Type of Acct: ______checking ______Savings

Routing Number Account Number

This authority is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and manner as to afford COMPANY and FINANCICIAL INSTITUTION a reasonable opportunity to act on it.