REQUEST FOR AUTOMATIC 
                                       PAYMENT OF ASSESSMENTS
      Thank you for your interest in Electronic Funds Transfer. Please fill out the following information 
      to complete this request.
      HOMEOWNER AUTHORIZATION FOR ELECTRONIC FUNDS TRANSFER
      I authorize the branch and the financial institution listed below to debit my bank account 
      automatically for each association assessment billing period. Note: Information below is required. 
      If not provided, there will be delays in processing your direct debit request.
      Management Company Name: Associa Mid-Atlantic
      Homeowner Name:
      Homeowner Account Number:
      Association Name: The Village Grande at English Mill
      Address And Unit #:
      City:       State:       Zip:
      Direct Debit Start/Stop Date (MM/YYYY):                           /
      Homeowner Bank Name:
      Homeowner Bank Routing Number:
      Homeowner Bank Account Number:
                  CHECKING ACCOUNT – Include a voided check from the account you would like to debit
                  SAVINGS ACCOUNT – Include letter from bank that includes your full account number and 
                  routing number. Statements will not be accepted.
              Only checks for US Banks will be accepted. Deposit slips cannot be used in place of a voided check.
      Signature:                                            Date: _______________
      In order for funds to be pulled in time for next month’s assessment, this form must be received no later than the 20th of 
      the prior month. The automatic payment process will begin with your next assessment period once we have received your 
      completed form and either your voided check or letter from bank that includes your full account number and routing number.
       Return by email: Scan and send this form and a voided check to: 
                             csscdirectdebit@associa.us
                Return by mail:                                     Associa
          Complete and send this form and a    OR              1225 Alma Rd., Suite 100
         voided check to the following address:                Richardson, Texas 75081
                  Delivering unsurpassed management and lifestyle services to communities worldwide.
           Form # CSSC-AR-0100               1                     V1.1, 03/28/2016