Checking Account Debit Authorization Fields that have an * are required. "*" indicates required fields This form allows Howell Dance to have your child's tuition taken out of your checking account monthly through May 2024Use this form to convert your account to automatic monthly payments from your checking account. You must upload a photo of a Voided Check at the end of this form.Student's Name* First Last Name On The Bank Account* First Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Checking Account InformationPlease debit payments from my checking account, below.Routing Number* Valid Routing # must start with 0, 1, 2, or 3Account Number* Consent – authorization* I authorize Howell Dance to process debit entries to my account. I understand that this authority will remain in effect until I provide reasonable notification to terminate the authorization.Consent – late fee* I understand that Howell Dance will debit my checking account for any outstanding costume balances not paid by the due date with a $10 late fee.Upload a photo of a VOIDED check.*Max. file size: 50 MB.Your Name – As Your Digital Signature* CommentsThis field is for validation purposes and should be left unchanged.