Leisure World Community Association Form

PAY YOUR MONTHLY BILLS AUTOMATICALLY BY SUREPAY

By signing up for SurePay, your Association Fees, monthly Golf membership and other charges, excluding fines, can be paid automatically via electronic transfer each month out of most Checking or Savings Accounts in the United States. Your bank account will be charged no earlier than the THIRD of each month.

1. Please be certain your Manor account is brought current before admitting SurePay form.
2. Print your name, manor #, date and sign where indicated at the bottom of this form.

Note: If this form is turned in the last day of the month, your payment will be withdrawn from that account in the following month.

I (we) hereby authorize Leisure World Community Association, hereinafter called COMPANY, to initiate debit entries to my (our) checking account indicated below and the depository named below, hereinafter called DEPOSITORY, to debit the same to each account.

This authority is to remain in full force and effect until COMPANY and DEPOSITORY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it. I (or either of us) have the right to stop payment of a debit entry by notification to DEPOSITORY at such time as to afford a DEPOSITORY a reasonable opportunity to act on it prior to charging account.

Form #10 Sure Pay (Revised 11-12-14)