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Auto Pay Form - ACH

CHS Automatic Payment Agreement

By submitting this form, you are agreeing to allow Congregation Har Shalom to automatically process payments for the transactions you indicate below.

This Agreement will remain in effect until:

  • You verbally (by phone or signed letter) or electronically (by email or website contact us form) cancel this agreement.
  • The Bank Account you have provided is closed
  • The Credit Card you have provided expires.
  • Any balance on your Account has been paid in full and you have completed or withdrawn from the Programs/Classes the automatic payment was set up for; or if you have resigned as a Member.

If you decide withdraw from any Programs/Classes you are registered for, or cancel your Har Shalom Membership, you are still responsible for paying any outstanding charges UP TO and INCLUDING the date of cancellation.
All Automatic Payments are processed on the 1st and/or 15th of each month.

If you are a CHS Member and login to your CHS Account, your information will automatically populate in the contact information fields below.

ACH - Select the charges you agree to Auto-Pay with Direct Checking Account Withdrawal


I authorize the CHS Office to pay for all of the checked items above with the CHECKING ACCOUNT provided below.
Enter an amount above that you would like to pay automatically each month
Enter N/A or "0" if you only wish to pay occasionally with ACH 
*ENTER  N/A  IF YOU ALREADY HAVE AN ACH ACCOUNT ON FILE.

Please enter the following information in the space provided above:
- Bank Name
- Bank Routing Number
- Checking/Savings Account Number

By typing my name in the box above, I am "signing" this agreement and authorizing Congregation Har Shalom to process payments on my Har Shalom Account as indicated in the form above.

Mon, May 20 2019 15 Iyyar 5779