The Dobson Association, Inc. 2719 S. Reyes ♦ Mesa, AZ 85202 ♦ (480) 831-8314
Pre-Authorized Electronic Assessment Payment Agreement - ACH Effective Date: _____________________ Name: ___________________________ Dobson Ranch Acct Number: _________________________ Address of Dobson Ranch Property: ______________________________________________________ Telephone: ___________________________________ Home
____________________________________ Cellphone/Work
Please complete bank information below and attach a voided check Bank Name: ____________________________________ Routing Number: ___________________________ Account Number: __________________________
Please note: The order of the routing number, check number and account number will not always be in the same position. If you can identify the check number and your checking account number, the 9-digit number remaining is the bank routing number.
I hereby authorize The Dobson Association, Inc. to initiate debit entries from my account at the bank named above. I understand the debit will be done on the 5th of each month with the money being withdrawn 1-2 days afterwards. This authority is to remain in full force and effect until The Dobson Association, Inc. has received written notification from me of its termination in a manner as to afford a reasonable opportunity to act upon it. Notice of any future rate change to your HOA assessment will be published in the Oct. or Nov. issue of the Ranchers’ Round Up, no coupons will be issued. Please note that in the event of a rate change, the Dobson Association will adjust the debited amount accordingly. I understand that if I cannot provide a voided check, and that I provide a routing or account number that is returned by the bank, I will incur a $20.00 NSF Fee. I also understand that if my ACH is returned by the bank for non-sufficient funds, I will incur a $20.00 NSF Fee. _______________________________________ Signature
Rev.2/2019
____________________________________ Date