ACH Enrollment Form

Back to ACH payment plan page

You must print this form out, sign it and send with your $20 non-refundable application fee to:

Office of Student Accounts
147 Le Mans Hall
Notre Dame, IN 46556

AUTHORIZATION AGREEMENT FOR SAINT MARY'S COLLEGE ACH MONTHLY PAYMENT PLAN:

I (we) hereby authorize Saint Mary's College, hereinafter called COLLEGE, to initiate Debit entries to my (our) Bank account indicated below and the bank named below, hereinafter called the DEPOSITORY, to debit my checking account:

STUDENT'S SOC. SEC#
AMOUNT TO BE WITHDRAWN
$
STUDENT'S NAME
DEPOSITORY(Bank) NAME:
Bank's CITY: STATE:

This authority is to remain in full force and effect until COLLEGE and DEPOSITORY have received written notification from me (or either of us) of its termination at least five business days before the next withdrawal occurs.

ACCOUNT HOLDER NAME(S) (Two signatures required for joint bank account)

PLEASE ATTACH A VOIDED CHECK.

1. __________________________________Date__________
(Please Print) (Signature)
2. __________________________________Date__________
(Please Print) (Signature)