T: +1 671.735.2940/2945 F: +1 671.734.2907 W: www.uog.edu
Mailing Address: 303 University Drive UOG Station Mangilao, Guam 96923
The University of Guam is a U.S. Land Grant Institution accredited by the Western Association of Schools and Colleges
Senior College and University Commission and is an equal opportunity provider and employer.
ACH PAYMENT AUTHORIZATION FORM
One-time Recurring Cancellation
Schedule your payment to be automatically deducted from your Checking or Savings Account.
How One Time Payments Work:
You authorize a one-time debit to your Checking/Savings Account.
How Recurring Payments Work:
You authorize monthly scheduled charges to your Checking/Savings Account.
Please complete the information below:
I, ______________________________ authorize the University of Guam to debit my
Account Holder’s Full Name
Checking/Savings Account as indicated below for $______________ to start on the 30th of
Amount
every month. Effective the month of _____________________. This payment will credit
Month and Year
_____________________________ for the following semester(s) ________________.
Student’s Name and ID# Ex: FA16/SP17
Total amount paid from scheduled payments $______________________.
Ex: $2000.00
Billing Address ____________________________ Phone# _________________________
City, State, Zip ____________________________ Email _________________________
Checking/Savings Account Information
Checking Savings
Name on Account _____________________
Bank Name _____________________
Account Number _____________________
Bank Routing # _____________________
Bank City/State _____________________
A receipt for each payment will be emailed to you.
SIGNATURE DATE
I understand that this authorization will remain in effect until I cancel it in writing. I agree to notify the University of Guam’s Bursar’s Office in writing of
any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment
dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings
account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted
periodic transaction dates. In the case of a rejected ACH Transaction or a denied credit card charge for Non-Sufficient Funds (NSF), I understand that
UOG may at its discretion attempt to process the charge again within 5 days, I agree to an additional $25.00 fee for each attempt returned NSF. This
fee will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my
account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute these
scheduled transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated in this authorization form.
Form 5002