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Automatic Payment Request Form

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  • Any balance on your Account has been paid in full and you have completed or withdrawn from the Programs/Classes the automatic payment was set up for; or if you have resigned as a Member.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  IF YOU ARE NOT SIGNING UP FOR AUTO PAY WITH ACH

If you ARE signing up to Auto-Pay with ACH, enter the following information in the space provided above:
- Bank Name
- Bank Routing Number
- Checking/Savings Account Number


CREDIT CARD FEE PAYMENT AGREEMENT

* CHS Credit Card Policy - As of July 1, 2018, all payments made with a credit card must include the convenience fee that is calculated on the CHS website's payment page.

  • Har Shalom pays thousands of dollars each year in credit card processing fees
    • Har Shalom is charged at least 3% of the total amount of EVERY credit card transaction.  
  • Your Payment of these Credit Card fees is 100% tax deductible! 
    • Each payment will be considered a donation to Har Shalom and will be included on your annual CHS tax statement.
If you DO NOT wish to pay these fees:
  • Complete the ACH - Automatic Checking/Savings Withdrawal section of this form (above),
  • OR exit this form and make payments with Personal or Bank-Issued Checks or Cash.

If you agree to pay these fees, select the charges you agree to Auto-Pay with a Credit Card below.

I authorize the CHS Office to automatically process payments for all of the checked items above with the CREDIT CARD information provided below.
Enter an amount above that you would like to pay automatically each month
* ENTER  N/A  IF YOU ARE NOT SIGNING UP FOR AUTO PAY WITH CREDIT CARD

If you ARE signing up to Auto-Pay with a Credit Card, enter the following information in the space provided above:
- Bank Name
- Card Holder's Name
- Credit Card # (####-####-####-####)
- Expiration Date (MM/DD/YYYY)
- CVV Code (3-digit code on back of card)
- Billing Zip Code

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.

Thu, December 13 2018 5 Tevet 5779