eps enrollment form · web viewconqueryourdebt.org f: 218.529.2255 800.764.0351 218.529.2255 424 w...

424 W Superior St. Duluth, MN 55802- 0306 800.764.0351 F: ConquerYourDebt.o Electronic Payment Service (EPS) - Enrollment Form Client Name: Client ID# Street/PO Box: City, State, Zip: Name of Depositor as shown on bank records: I (we) authorize LSS Financial Counseling to debit my (our) account indicated by the attachment below for my (our) scheduled contract amount of: Checking or Savings $ . 00 CHECK ONE OF THE FOLLOWING WITHDRAWAL DATES: 2 nd of Each Month (if your due date is the 5 th ) 7 th of Each Month (if your due date is the 10 th ) 12 th of Each Month (if your due date is the 15 th ) 16 th of Each Month (if your due date is the 20 th ) START MY FIRST EPS WITHDRAWAL IN THE MONTH OF: ___________________________________ (Please allow a minimum of 25 days for processing) Note: Please call our Client Service Team if you have questions regarding your due date. I have read and understand the enclosed Electronic Payment Service (EPS) Guide. I am aware that LSS Financial Counseling can end my EPS service if my account has insufficient funds or a ‘stop payment’ at the time of any withdrawal date listed above. Depositor Signature: _______________________________________________ Date: ____________________ Client Signature: _______________________________________________ Date: ____________________ Co-Client Signature: _______________________________________________ Date: ____________________ 05/30/14 Internal Use Only A D EPS E Please Attach Blank Voided Check (For Checking) -Or-

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424 W Superior St. Duluth, MN 55802-0306800.764.0351 218.529.2255F: 218.529.2255

ConquerYourDebt.org

Electronic Payment Service (EPS) - Enrollment Form

Client Name: Client ID# Street/PO Box: City, State, Zip: Name of Depositor as shown on bank records:

I (we) authorize LSS Financial Counseling to debit my (our) account indicated by the attachment below for my (our) scheduled contract amount of:

Checking or Savings $ . 00 CHECK ONE OF THE FOLLOWING WITHDRAWAL DATES:

2nd of Each Month (if your due date is the 5th)

7th of Each Month (if your due date is the 10th)

12th of Each Month (if your due date is the 15th)

16th of Each Month (if your due date is the 20th)

START MY FIRST EPS WITHDRAWAL IN THE MONTH OF: ___________________________________(Please allow a minimum of 25 days for processing)

Note: Please call our Client Service Team if you have questions regarding your due date. I have read and understand the enclosed Electronic Payment Service (EPS) Guide. I am aware that LSS Financial Counseling can end my EPS service if my account has insufficient

funds or a ‘stop payment’ at the time of any withdrawal date listed above.

Depositor Signature: _______________________________________________ Date: ____________________Client Signature: _______________________________________________ Date: ____________________ Co-Client Signature: _______________________________________________ Date: ____________________

05/30/14

Internal Use OnlyA

EPS EPlease Attach

Blank Voided Check (For Checking) -Or-

Blank Voided Deposit Slip (For Savings) Here