Anne Springs Close Greenway is pleased to offer you the pre-authorized payment plan service for your convenience. Your Preschool tuition will be automatically charged to your credit card on the 1st of each month or the first business day of the month. This plan eliminates the need for you to call each month to charge your credit card and allows us to better service your account.

Instructions: Complete the Automatic Credit Card Payment Authorization Form on this page and make a copy of the completed authorization form for your records.

Forms can be dropped off at the Complex or mailed to:

Anne Springs Close Greenway Recreation Complex

P.O. Box 280

Fort Mill, SC 29716

Attention: Dana Berger, Member Services Account Specialist

I authorize Anne Springs Close Greenway (ASCG) to initiate charges to my credit card account. I authorize the credit card company named to accept these charges to my credit card account. These payments will be charged as indicated below. The monthly tuition amount and payment schedule is listed below by class. Note that any changes in membership status will affect your automatic monthly credit card tuition payment.

This authorization is to remain in effect for the Preschool 2013-2014 school year. To cancel this automatic payment, I must provide written notice of cancellation to ASCG not less than 30 days prior to the next scheduled payment. ASCG may terminate this payment plan upon notice of two (2) declined transactions. ASCG reserves the right to cancel this agreement with prior written notice. ASCG will notify me of any changes in the dollar amount charged to my account. ASCG shall not be liable for losses caused by the credit card company’s failure to act in accordance to this request.

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Child’s Name (Please Print) Cardholder’s Name

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Email Address

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Home Address City State & Zip Code

Effective Date of this Authorization: ______- 6/1/2014 $______

Monthly Tuition

Monthly Rates: ( ) Complex Member [M] ( ) Non-Member [NM]

Month / Post Date
September / 9/1/2013
October / 10/1/2013
November / 11/1/2013
December / 12/1/2013
January / 1/1/2014
February / 2/1/2014
March / 3/1/2014
April / 4/1/2014
May / 5/1/2014

Type of Credit Card to be Charged (Check One): ( ) Visa ( ) Mastercard ( ) Discover

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Credit Card Number Expiration Date (mm/yy)

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Customer Signature Date