MAKE A PAYMENT

By checking this box, I authorize the merchant to debit my account for the amount shown in the request on the date selected. I understand that I can revoke this authorization at anytime with 1 day's notice.

I understand that this authorization is for a one time payment. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non-Sufficient Funds I understand that the merchant may, at its discretion, attempt to process the charge again within 30 days. And agree to an additional 2% charge for each attempt returned which will be initiated as a separate transaction to my account which must comply with the provisions of US law.

I certify that I am an authorized user of this bank account and will not dispute these scheduled transactions with my bank; so long as the transactions correspond to the terms indicated in this authorization form.