2. Direct Payment Authorization Form: Fixed Payments

4. We are pleased to offer you a new service-the Direct Payment Plan. Now you can have your payment deducted automatically from your checking or savings account. And, you won’t have to change your present banking relationship to take advantage of this service.

   The Direct Payment Plan will help you in several ways:

   • It saves time – fewer checks to write and mail.

   • Helps pay your bills in a convenient and timely manner – even if you’re on vacation or out of town.

   • Your payment is always on time – it helps maintain good credit.

   • It saves postage –many people spend close to $100 a year on postage.

   • No late charges.

   Here’s how the Direct Payment Plan works:

   You authorize regularly scheduled payments to be made from your checking or savings account. Your payments will be made automatically on the specified day and proof of payment will appear on your bank statement.

5. The authority you give to charge your account will remain in effect until you notify us in writing to terminate the authorization. If the amount of your payment changes, we will notify you at least 10 days before the effective payment date. The Direct Payment Plan is dependable, flexible, convenient and easy. To take advantage of this service, complete and submit the below authorization form,

   All you need to do is:

   1) Indicate whether your payment will be deducted from your checking or savings account by marking the box to the left of the account type.

   2) Fill in your name, financial institution name and location, and the starting date.

   3) Attach a voided check, deposit slip or printed verification from your financial institution with all financial institution information.

   4) Check the box acknowledging your understanding that you are allowing the York County Clerk of Courts Office to remove funds from your bank account.

7. Please complete the information below

9. Check one*

   1. 1st of the month

   1. 15th of the month
11. I authorize York County Clerk of Courts to initiate electronic debit entries to my:*

    1. Checking Account

    1. Savings Account

    
    
    for payment of my Cost & Fines.

13. Debit Amount*
15. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. This authority will remain in effect until I have cancelled it in writing.*
17. Starting Date*
    Starting Date
19. Financial Institution Name*
20. Financial Institution City and State*
22. Financial Institution Routing Number*
23. Account Number at Financial Institution*
25. Name*
26. Date of Birth*
    Date of Birth
28. Phone Number*
30. Case Number OR Payment Plan Number
32. Attach a voided check, deposit slip or printed verification from your financial institution with all financial institution information.*

34. *Payments returned for Insufficient Funds will be charged a $50 fee.

36. By checking this box you acknowledge your understanding and are allowing the York County Clerk of Courts Office to remove funds from your bank account listed above*
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit

* indicates a required field