automatic payment plan agreement PDF download

Automatic Payment Plan Agreement

Authorization for Direct (ACH/CREDITS)
  • Consent

    I (we) hereby authorize LaMarco Systems, Inc. to initiate debit/credit enteries to my (our) Checking Account indicated on the attached voided check at the depository financial insitution named on such document, hereinafter called DEPOSITORY, and to debit/credit the same to such account. I (we) acknowledge that the origination of LaMarco Systems, Inc. transactions to my (our) account must comply with the provisions of U.S. law.
  • This authorization is to remain in full force and effect until (please select a date from the calendar above) has a written notification (signed by all names on bank account) of its termination in such time and in such matter as to afford LaMarco Systems, Inc. a reasonable opportunity to act on it.
  • Accepted file types: jpg, gif, pdf.
    Please scan and attach an image of the voided check.
  • Note:

    ALL WRITTEN DEBIT/CREDIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION.
  • This field is for validation purposes and should be left unchanged.