Authorization Form Template

TELLURIDE WEST CONDOMINIUMS Direct Payment Plan ASSOCIATION, INC. Authorization Form PO Box 16550 Golden, CO 80402 This form should be received by the Association no later then the 20th of the month to start the withdrawal for the next months assessments.

The Telluride West Condominiums Association offers ACH Direct Payment for the Association Dues Payment. If you chose to use this service please complete this form and return it to the above address. Your dues amount will be deducted monthly from your bank account, notice is sent only when the amount changes. The amount will be based upon the prorata share of your condominium unit based upon the approved current years budget. Please fill out one form for each unit (if you own more than one unit).

All you need to do is:

1. Mark the box before type of account to indicate whether your payment will be deducted from your checking or savings account. 2. Fill in your name, financial institution name and location and date. 3. Attach a voided check for verification of all financial institution information. If you are unable to attach the voided check, please fill in your account number and routing number. NOTE: Be sure to sign the form!

AUTHORIZATION FOR DIRECT PAYMENT I authorize Telluride West Condominiums Association, Inc. to initiate electronic debit entries to my: checking account or savings account for payment of my monthly condominium dues assessment. I understand I will receive a notice if the amount changes. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. This authority will remain in effect until I have cancelled it in writing.

Date ______

Financial Institution Name (Please Print) ______

Account Number at Financial Institution ______

Financial Institution Routing/Transit Number ______

Financial Institution City and State ______

Unit Owners Name ______

Unit Address______Unit Number______

Telluride West Account Number______

Signature ______

PLEASE KEEP A COPY OF THE AUTHORIZATION FOR YOUR RECORDS

Staple Voided Check Here

Please return this form by U S Postal Service, Fax or hand deliver to our office. DO NOT E-MAIL