Ugly Bus Retirement Fund
Direct Draft Sign up form
ACCOUNT INFORMATION
_________________________________________
Name on Checking Account
________________________________________________________________________________
Bank Name/City/State
Account Number ____________________________
Routing Number _________________________
Checking Acct. _____ or Savings Acct. _____
I hereby authorize Mountain Discovery Charter School to draft a payment from my account listed above.
Attached is a voided check for the checking account, and/or a deposit slip for the savings account designated
above.
Check the following, as applicable:
_____Begin my ________ monthly, direct draft payments of ___________
No. of pmts.
Pmt. Amt.
_____ Begin my ________ annual, direct draft payments of ___________.
No. of pmts.
Pmt. Amt.
____________________________________
Signature
Attach voided check here!!!!