Direct Debit Form

Payments By Direct Debit

For your convenience, the Ladies Pennsylvania Slovak Catholic Union is happy to announce that your can now pay your premiums by Direct Debit. All you have to do is complete the authorization form below and attach a voided check or savings deposit slip.

Name(Required)

First Last

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Certificate Number(Required)

Select one of the following:(Required)

New Authorization

Change Financial Institution (Bank)

Payment will be debited on the 15th of every month or the next working day.

Total Amout of Premium(Required)

Type of Account:(Required)

Checking (Attach Voided Check)

Savings (Attach Deposit Slip)

Upload Files(Required)

Drop files here or

Max. file size: 8 MB.

Effective Start Date(Required)

Would you like to recieve a letter when your premium is paid?(Required)

Yes

I hereby authorize the Ladies Pennsylvania Slovak Catholic Union to process debit entries to my account. I have attached a voided check or savings deposit slip. This authorization will remain in effect until I give written notice of its termination.

Signature(Required)

Date(Required)

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