Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Direct Debit Program Authorization Agreement

  1. Website Fillable Form Header
  2. Direct Debit Program Conditions & Terms
    This authorization agreement for enrollment must be received by Lake Ridge Parks & Recreation Association, Inc. (LRPRA) no later than the fifteenth (15th) day of the month proceeding the month you wish to start Direct Debit. You will be notified when your enrollment in the program is finalized.
  3. LRPRA will request the transfer of direct debit funds on a quarterly basis according to LRPRA’s fiscal year: September 1, December 1, March 1 & June 1 of each year. LRPRA is authorized to debit funds from my checking account for deposit into the Association’s account between the first (1st) and fifth (5th) working day of the month. The debit will be processed through Union Bank, N.A.
  4. The amount debited from my account will equal the current regular quarterly assessment and may include special assessment(s) if applicable. I recognize there may be other charges applied to my account but the direct debit will not include such charges, additional fees, handling charges, etc. unless specifically authorized.
  5. I am completely responsible for notifying LRPRA in writing (by letter or email to finance@lakeridgeva.com) by the fifteenth (15th) of the preceding month of any changes to my account (i.e. change of bank, accounts numbers, property sale, etc). Failure to notify LRPRA by the fifteenth (15th) of the preceding month may result in funds being withdrawn in the following month. Any charges caused by this debiting and failure to notify LRPRA will be the sole responsibility of the homeowner.
  6. An account with two (2) returned payments (insufficient funds (NSF), account closed, etc.) in a year will be ineligible to continue in the direct debit payment program.
  7. If a direct debit is not honored by my bank, I will be responsible for making up that payment by check immediately upon notification. I am also responsible for any related NSF/returned payment fees charged by the bank and LRPRA. These charges will be added to my account.
  8. My Association assessment account must be current with a zero balance (no other unpaid charges).
  9. Conditions & Terms Agreement*
    I acknowledge the above Conditions and Terms and authorize Lake Ridge Parks & Recreation Association, Inc. (LRPRA) to process direct debit entries to my checking account as indicated below and the financial institution listed below to debit same account.
  10. (If known)
  11. (9 digits)
  12. Where to find routing & account numbers on your checks:
    Check Example
  13. Notification of Termination Agreement*
    This authorization is to remain in full force and effect until LRPRA receives written notification from me of its termination.
  14. Electronic Signature Agreement*
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
  15. Leave This Blank:

  16. This field is not part of the form submission.