Automated Payment Plan Agreement

AUTOMATED PAYMENT PLAN AGREEMENT

PAPERWORK REDUCTION ACT AND PRIVACY ACT STATEMENT

The following information is provided to comply with the Privacy Act of 1974 (P.L. 93-579). The information requested on the form is required under various provisions of title 15 U.S.C. 1601, 12 CFR 205 and 202, for the purpose of providing authority to Robert Morris College to designate financial institutions to collect payments, by electronic means, from your account. The information will be used for identification with the records of the student and the financial institution to direct your payments to the point you authorize. No deduction may be made unless an authorization form is received. Failure to furnish this information may delay or prevent the collection of these payments through the ACH system.

* Required information

I would like to:

Enroll in the Automated Payment Plan Discontinue the Automated Payment Plan

1. STUDENT INFORMATION

Student Name:

Student ID #:

RMC Email Address:

Student Telephone #:

2. BANK INFORMATION

Payments should be made from (select one):

Checking Account Savings Account

Name on Bank Account:

Telephone #:

Bank Name:

Bank Routing # (9 digits):

Bank Account #:

3. CREDIT CARD INFORMATION

Payments should be made from
(select one):

Master Card Visa Discover American Express

Name on Credit Card:

Billing Address
(Same as the billing address shown on credit card):

Billing City, State, Zip:

Telephone #:

Credit Card #:

Exp:

Credit Card Security Code
(Last 3 digits on back of Visa, MasterCard, Discover cards) or (last 4 digits on front of American Express card):

4. RECURRING MONTHLY PAYMENT SCHEDULE

Estimated Balance Due:

Divided by # of months:

= Estimated Monthly Tuition Payment:

PLUS THE FULL AMOUNT OF ANY BOOKSTORE CHARGES OR OTHER
MISCELLANEOUS CHARGES OR OTHER CHANGES TO THE FINANCIAL PLAN*

will be deducted the 1st of every month from your account as authorized beginning

Month:

Year:

*The actual monthly tuition payment is subject to change based
upon actual charges and eligibility for Financial Aid.

5. APPROVAL

I authorize RMC to debit my account on the 1st of each month for the total
amount due. The total amount due will include the monthly tuition payment
PLUS the full amount of any bookstore charges or other miscellaneous charges.
This authority will remain in full effect until revoked by me, my financial institution,
or by Robert Morris College.