Tennessee Farm Bureau Federation
Authorization for Payment by EFT
Membership Name: Member #:
B
ank Name
: A
ccount Type:
R
outing #
: A
ccount #
:
Debit Entries: As a convenience to me, I hereby authorize Tennessee Farm Bureau Federation (TFBF) to initiate debit
entries to the account identified above for annual membership payments (the charge) on the membership set forth
above. I acknowledge that I am signing this agreement on behalf of all family members on the membership, and
signatories to the account and am authorized to do so.
Terms of Authorization: I understand and agree that this authority is to remain in full effect until TFBF and the bank
identified above (Bank) have received written notification from me of its termination in such time and in such manner
as to give TFBF and Bank a reasonable opportunity to act upon it. I agree that TFBF's treatment of such charge, and
TFBF's rights in respect to it, shall be the same as if it were signed personally by me. I further agree that if any
electronic funds transfer (EFT) for membership payment is not honored when presented to the bank on which it is
drawn, whether with or without cause and whether intentionally or inadvertently, a $5 late fee will be added to my
dues. If said charge is not remedied within thirty days from the assigned date of the charge, then my membership will
release. Additional fees may apply for charges not honored.
Date and Amount of Charge: I understand and agree that the charge shall be scheduled to occur on or about the same
day of each year based upon the membership period dates. Variances in the charge date may occur due to weekend and
holiday processing.
Cancellation and Lapse: I understand and agree that this payment plan and the membership to which it relates may be
cancelled by me at any time in accordance with membership provisions. Membership may also lapse for non-payment
or be cancelled by TFBF for any other reason in accordance with membership provisions.
Reinstatement: I understand and agree that if this membership lapses for non-payment, or if it is cancelled in
accordance with membership provisions, if and when the membership is reinstated the date of the charge will change to
the new due date set by TFBF.
Miscellaneous: I understand and agree that all changes in account information must be received by TFBF no later
than one (1) business days before payment is scheduled to be made. This agreement is subject to change or
cancellation by TFBF upon notification.
I hereby agree to the terms and conditions stated in this form on behalf of all members.
B
ankholder’s Signature
:
Date:
