Beneficial Farms CSA, Inc. Payment Pre-authorization
Beneficial Farms CSA, Inc. Payment Pre-authorization Form I, ___________________________________________________________________________ understand and agree to have Beneficial Farms CSA, Inc. recharge my Farm Account through an electronic payment process and that the CSA will notify me via email five business days before this transaction is due to post to my bank account. I understand and agree that it is my responsible to notify the CSA immediately if other financial arrangements need to be made. Furthermore, I agree to hold the CSA harmless for any banking or service charges that may occur should my account have insufficient funds to cover the transaction. My Email Address: _____________________________________________________________________________________________ I hereby authorize Beneficial Farms CSA, Inc. to initiate debit entries, and if necessary, credits and adjustments for any debit entries in error to my account indicated below and the depository named below. The amount I have circled below indicates the dollar amount that will be charged to my bank account on the 20th of every month to begin on _____________________________________.(enter date). The re-charge amount is based on the usage level of my Farm Account . Farm Share
$150
Farm Share + Eggs $150
Farm Share + Cheese $ 200
Farm Share + Eggs + Cheese $ 200
Farm Share + Beef
Farm Share + Eggs + Cheese + Beef
$200
$225
Checking/Savings (circle one) Routing # ____________________________ Account # ____________________________________ DEPOSITORY Name ____________________________________________________ Branch ________________________________________ City _______________________________________________________ State _______________________ Zip _______________
This authority is to remain in full force and effect until Beneficial Farms CSA, Inc. has received a 30day written notice of cancellation from me of its termination in such time and in such manner as to afford Beneficial Farms CSA, Inc. a reasonable opportunity to act on it. I hereby acknowledge that I understand and agree to the terms as outlined above. ____________________________________________________________________________________________________________________ Signature Date ____________________________________________________________________________________________________________________ Name (printed)
FOR INTERNAL USE ONLY
Date completed form was received: _______________
Date electronic payment account was set up: _______________
Beneficial Farms CSA, Inc. PO Box 30044, Santa Fe, NM 87592 [email protected] | 505-470-1969 | www.beneficialfarm.com
$150
Farm Share + Eggs $150
Farm Share + Cheese $ 200
Farm Share + Eggs + Cheese $ 200
Farm Share + Beef
Farm Share + Eggs + Cheese + Beef
$200
$225
Checking/Savings (circle one) Routing # ____________________________ Account # ____________________________________ DEPOSITORY Name ____________________________________________________ Branch ________________________________________ City _______________________________________________________ State _______________________ Zip _______________
This authority is to remain in full force and effect until Beneficial Farms CSA, Inc. has received a 30day written notice of cancellation from me of its termination in such time and in such manner as to afford Beneficial Farms CSA, Inc. a reasonable opportunity to act on it. I hereby acknowledge that I understand and agree to the terms as outlined above. ____________________________________________________________________________________________________________________ Signature Date ____________________________________________________________________________________________________________________ Name (printed)
FOR INTERNAL USE ONLY
Date completed form was received: _______________
Date electronic payment account was set up: _______________
Beneficial Farms CSA, Inc. PO Box 30044, Santa Fe, NM 87592 [email protected] | 505-470-1969 | www.beneficialfarm.com
