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AR CARD AUTHORIZED & SIGNED DEBIT AGREEMENT(2)

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Case number*

Total Amount Agreed Be Paid*

Number of Payments*

Please enter a number from 1 to 15.

Date of 1st Payment*

Amount of Payment*

Date of 2nd Payment*

Amount of Payment*

Date of 3rd Payment*

Amount of Payment*

Date of 4th Payment*

Amount of Payment*

Date of 5th Payment*

Amount of Payment*

Date of 6th Payment*

Amount of Payment*

Date of 7th Payment*

Amount of Payment*

Date of 8th Payment*

Amount of Payment*

Date of 9th Payment*

Amount of Payment*

Date of 10th Payment*

Amount of Payment*

Date of 11th Payment*

Amount of Payment*

Date of 12th Payment*

Amount of Payment*

Date of 13th Payment*

Amount of Payment*

Date of 14th Payment*

Amount of Payment*

Date of 15th Payment*

Amount of Payment*

Total

Email*

First Name*

Last Name*

Phone

Card Number*

Expiry Date*

CV2 Code*

Billing Address*

Street Address

City

State

Zip Code

Legal Authorization To Debit Account*

By signing this form you give us permission to debit your account for the amount indicated on or after the date(s) below. This is permission for transaction on date(s) listed below.

TERMS & CONDITIONS

I hereby authorize debit(s) to the above account, on the dates listed above. I certify that I am an authorized user of this account. I make this agreement willingly and understand that any attempt to file a dispute or chargeback for any of the charges covered under this agreement will initiate an immediate banking security audit.

I CONSENT TO ALL CALLS AND TEXT MESSAGES RELATED TO THIS MATTER

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Date & Time