Heritage Village Condominiums
Direct Debit Authorization Form

Name:          _______________________________________________________


Unit:             _______________________________________________________


Signature:     _______________________________________________________


Date:            _______________________________________________________

Please complete the above information and return this form to:

    Dana Tiblier Management Services, Inc.
    1994 Gallatin Pike North
    Suite 307
    Madison, TN  37115


You must also enclose a voided check.

Authorization provided by and through this form will only be used to debit the account you provide for monthly maintenance fees. Only the amount of your maintenance fee will be debited. If you have an outstanding balance with the Association, you must forward payment separately.

The unit owner is responsible for any and all bank charges incurred as a result of insufficient funds, stop payment, or closed account, whether incurred by the unit owner at their financial institution or the financial institution of the Heritage Village Condominiums Homeowners’ Association. Direct debits returned for insufficient funds will be subject to the standard late fee of $20.00.

Executed form must be received by the 1st day of the month in order to process direct debit for that month. Written notice must be received to discontinue direct debit of you account.