"*" indicates required fields Homeowner InformationAssociation Name*Homeowner Name(s)* First Last Homeowner Address* Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Homeowner ID #Is this Authorization a...* New Addition Change Deletion Account InformationI hereby authorize Ponderosa Community Management, hereinafter called company, to initiate debit entries for the current balance due from the account and the depository indicated below.Effective Date* MM slash DD slash YYYY Name on Account* First Last Depository*Banking Transit / ABA #*Account No.*Account Type* Checking Savings VOIDED CHECK Drop files here or Select files Max. file size: 32 MB, Max. files: 2. Upload a copy of a VOIDED check.Note: Payments will be drawn between the 3rd - 5th of the month. AuthorizationThis authority is to remain in full force and effect until Company and Depository have received written notification from me of its termination in such time and in such manner as to afford Company and Depository a reasonable opportunity to act on it.Authorized Signature for Account*Printed Name* First Last Date* MM slash DD slash YYYY Authorized Signature for Account (if second signature is required)Printed Name First Last Date MM slash DD slash YYYY To receive an email verification of receipt and start date, please provide us an email address:Email Address Δ
