ACH Payment Authorization

By this authorization, you agree to the regularly scheduled charges to your Bank Account. In each billing period, you will be charged the indicated amount below. You will be provided with a receipt for each payment and the charge will appear on your Bank Account Statement. In the event the billing date or the amount charged changes, you agree that notice of such change will be provided to you by us at least 10 days before the payment due date.

I
allow Bulanin RG to charge my Bank Account monthly tuition fee below for $
as of the 1st of JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember and continue to charge on the 1st of each following month.

Services Provided: Rhythmic Gymnastics Classes

Billing Details
Billing Address
Street City State —Please choose an option—ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Phone Number Email

Bank (ACH) Information Checking AccountSavings Account Account Owner Bank Name Account Number Routing Number

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the BRG in writing of any changes in my account information or termination of this authorization at least 30 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF) I understand that the merchant may, at its discretion, attempt to process the charge again within 30 days. And agree to an additional $25.00 charge for each attempt returned NSF which will be initiated as a separate transaction to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank; so long as the transactions correspond to the terms indicated in this authorization form.

I understand that if I am not on automatic billing and my tuition is not paid by the 1st of the month, Bulanin Rhythmic Gymnastics will charge my credit card on file for the outstanding balance plus a $25 late fee. I understand that if my ACH payment is declined, I will incur a $25 processing fee.

Individual's Signature
Date