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1 similar Authorization Agreement for Automatic Payments contracts
ContractAuthorization Agreement for Automatic Payments • February 25th, 2011
AUTHORIZATION AGREEMENT FOR AUTOMATIC PAYMENTS ***ACH DEBITS/CREDITS*** Trans/ABA Number: Checking/Savings Account Number: Customer Name on Account: Address: City: State: Zip Code: Financial Institution: IMPORTANT: PLEASE ATTACH A VOIDED CHECK OR SAVINGS DEPOSIT SLIP WITH THIS FORM TO ENSURE ACCURATE PROCESSING. I hereby authorized Totah Communications, hereinafter called "COMPANY", to initiate debit entries, if necessary, credit and adjustment entries in error to my Savings account (select one) and the depository named above, hereinafter called "DEPOSITORY", to debit and/or credit the same to my account. There will be a $3.00 processing fee for all customers that are not setup on a recurring monthly basis and have this form on file. ***CREDIT CARD CHARGES / CREDITS*** Payment Method: VISA Security Code (three or four digits) Credit Card Number: Expiration Date: Name on Credit Card: Address: City: State: Zip Code: Telephone Number(s) to be paid by above method: I her
