I hereby authorize the Bella Vista Property Owners Association (BVPOA) to initiate debit entries (and credit entries if
necessary) to my bank account indicated below, and I request and authorize the financial institution named below to
accept and honor the same and to charge the same to my account. I understand that Assessment and Water
accounts should be current; the automatic bank draft authorized here will not collect funds for prior balances
due. I certify that I am an authorized user of this bank account and will not dispute these scheduled transactions with
my bank so long as the transactions correspond to the terms of this form.
Automatic Bank Draft
Authorization Agreement
Phone: (479) 855-8000 Fax: (479) 855-4901
Property Information (for assessments)
Member # ______________________________________
Sub-Blk-Lot ______________________________________
Sub-Blk-Lot ______________________________________
Water Information
Member # ______________________________________
Water Acct. # ______________________________________
Water Acct. # ______________________________________
Checking/Savings Information
Checking Savings
Name on Account ____________________________________
Bank Name _________________________________________
Bank Routing # ______________________________________
Bank Account # ______________________________________
Bank City/State ______________________________________
Check here to STOP Bank Draft
Stop Bank Draft
This authorization will remain in eect until the BVPOA has received written notication from me or my legal
representative in such time as to aord the BVPOA a reasonable time to act upon the termination.
Please complete the information below:
I, (print name) ____________________________________________ authorize the Bella Vista Property Owners Association to charge my
account as detailed below.
Billing Address_______________________________________________________________ Phone____________________________________
City, State, Zip _______________________________________________________________ Email_____________________________________
Signature ________________________________________ Date________________
Signature 2_______________________________________ Date________________
I authorize the following to be paid by Automatic Bank Draft:
Monthly Assessments - Drafts the 4
business day of the month: Yes No Owner
Monthly Water - Drafts the 15
day of the month: Yes No Renter
Note: If the draft date falls on a weekend or holiday, the bank draft will be made on the rst business day following those dates.
Bank Change
Mail completed form to:
POA Accounting Office
P.O. Box 6210 • Bella Vista, AR 72714
Rev. 12.03.2020
Both signatures required if joint bank account.
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