DEBIT DRAFT AGREEMENT

Brought to you as a service of 
Monitor Realty Management, Inc.
150 North Street, Suite 40
Pittsfield, MA 01201

     This form will generate a DEBIT DRAFT AGREEMENT, which you will need to sign and photocopy (or print twice). Please send the signed original to our office along with a voided check from your checking account ( the one to be debit drafted from). Keep a copy of the agreeement for your records. If you have any questions, please call Laurie LaHart at 1-800-351-3301.
     Thank you.

First Name
Middle Initial
Last Name
Street Address
City
State
Zip
Phone Number
E-Mail Address
Name of Bank
Street Address of Bank
Bank City
Bank State
Bank Zip
Checking Account Number
This section is for the accounts you wish us to pay. Please enter the creditor's name, the address, the account number, and the monthly amount to pay to each creditor.
Creditor Name Address Account Number Monthly Payment
   Enter the total amount you are authorizing us to deduct each month.
   Be sure to include the monthly fee to Monitor in this total.
  The next choice is of up to 4 days, each month, that we make deductions on. You may authorize deduction on one day only, or on several days if you wish to have your total monthly deduction taken out in smaller parts over the month. If for some reason you wish to have more than four debit drafts each month please call to make special arangements. 
   If you authorize a day that appears on a non-banking day in any month, your effective date of authorization for that month will be the next banking day.
Click on each day(s) that you authorize deduction(s) to be made on each month. Each of the first four Mondays
Both the First and Third Mondays 
Both the Second and Fourth Mondays 
The First Monday only 
The Second Monday only 
The Third Monday only 
The Fourth Monday only 
When you are satisfied with your entries, press the "Get Agreement" button to generate your agreement. A completed agreement will appear in your browser as a cgi mail file, print it sign it, and send it to us with a voided check. If you wish to make changes, you can clear this form by pressing the "Reset" button.
Billpay, a program of Monitor Realty Management, Inc.
(1-800-351-3301), ©Mory Brenner, Esq.
Last updated:  1/11/99 11:56:44 AM
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