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AGREEMENT FOR PRE-AUTHORIZED PAYMENTS (monthly)


I hereby authorize _____________________________, (Community) and KPG Accounting Services, Inc.
to initiate debit entries in the amount of my monthly assessments and any subsequent special assessments
from my account indicated below. I also authorize the Financial Institution named below to debit the same
such account.
Community (from above):*
Financial Institution Name:
Branch:
City:
State:
Zip:
Transit/ABA No.:
Account No.:
This authority is to remain in full force and effect until the Community and Financial Institution have
received written notification from me of its termination in such time and manner as to afford the
Community and the Financial Institution a reasonable opportunity to act upon the request. I further
understand that payments will be deducted from my account between the first and tenth of each month in
which the assessment is due, and should my payment be returned for any reason, I understand that I can be
terminated from the program and I will be charged a $25 administrative fee. PLEASE CONFIRM ROUTING # AND ACCOUNT # LISTED ARE CORRECT BEFORE SUBMITTING FORM
Name(s):
Property Address:
Phone No.:
Mailing address (if different):
Date:
Signed:
PLEASE RETURN TO:
KPG ACCOUNTING SERVICES, INC.
ATTN: KEVIN P. GAFFNEY
CONTACT@KPGACCOUNTING.NET
NEW OR UPDATE:
To prevent automated SPAM, please enter CWC to submit your form (case sensitive):*
 

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