I authorize Kentucky CASA Network to initiate, and my financial institution to honor, a one-time electronic debit from my bank account on the date, for the amount, and from the account listed.
I authorize Kentucky CASA Network to store my bank account information and initiate recurring electronic ACH debits from my indicated account, and authorize my financial institution to honor such payments. This authority is for the amount, dates, and frequency listed and is to remain in effect until canceled by Kentucky CASA Network, my financial institution, or me. I can cancel my authorization for recurring payments by contacting Kentucky CASA Network at (502) 238-2154. I also confirm that this constitutes my written authorization and electronic signature to enroll in recurring payments.
If paying by check, please remit to: Kentucky CASA Network, 1640 Lyndon Farm Court, Suite 108, Louisville, KY 40223
An invoice will be emailed to the address on this form.