Revised 7/25/18
AUTHORIZATION AGREEMENT FOR DIRECT DEBIT
FOR: CCMC
I (we) hereby authorize CCMC hereinafter called Company, to initiate debit entries to my (our) Bank account indicated
below at the depository named below, hereinafter called Depository, to debit the same to such account.
Depository Name:
CCMC as Agent of the Association
8360 E Via de Ventura, Ste 100 Bldg L
Scottsdale, Arizona 85258-3172
The authorization is to remain in full force and effect until COMPANY has received written notification from me (us) of its
termination in such time and such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.
Note: All written debit authorizations MUST provide that the receiver may revoke the authorization only by notifying the originator in
the manner specified in the authorization.
*** APPLICATIONS RECEIVED AFTER THE 29
TH
DAY OF THE MONTH PRIOR TO THE ASSESSMENT CHARGE WILL NOT BE PROCESSED UNTIL
THE NEXT BILLING PERIOD
EMAIL COMPLETED FORMS AND VOIDED CHECK TO ACHSETUP@CCMCNET.COM. INCOMPLETE OR INCORRECT INFORMATION IN ANY
*REQUIRED FIELD MAY DELAY THE PROCESSING OF THIS REQUEST, AND MAY CAUSE THE DIRECT DEBIT TO BECOME EFFECTIVE IN THE
NEXT BILLING PERIOD.
IF THERE ARE ANY QUESTIONS, PLEASE CONTACT YOUR COMMUNITY OFFICE OR CCMC’s CUSTOMER SERVICE OFFICE AT 866-244-2262
I wish to: (please indicate ONE) *-required field
Establish a new Direct Debit Account Change the bank account my debits are drawn on
Cancel my Direct Debit Account
Community/Association Name* (not “CCMC”):
Association Account #*: _______________________ Start Direct Debit on*: ____________________
(account # can be found on statement) (if unsure of start date, please contact community office or
CCMC’s customer service)
Association Account #*: ________________________ Start Direct Debit on*: _____________________
(account # can be found on statement) (if unsure of start date, please contact community office or
CCMC’s customer service)
Name(s)*:
Please Print Please Print
Email Address:
Specify ONE:* Checking or Savings
Routing # (9 digits)*: ________________ Account #*: (ATTACH VOIDED CHECK OR
OTHER VERIFICATION OF ROUTING AND ACCOUNT #)
FOREIGN BANK ACCOUNTS ARE NOT ELIGIBLE FOR THIS PROGRAM.
Signed*: X_______________________________ X
