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 2023

Use 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*
Name On The Bank Account*
Address*

Checking Account Information

Please debit payments from my checking account, below.
Valid Routing # must start with 0, 1, 2, or 3
Consent - authorization*
Consent - same checking account
Consent - late fee*
Max. file size: 50 MB.
This field is for validation purposes and should be left unchanged.