Today, being , I, , by
entering my routing and account number above and clicking “Authorize,” I authorize my payment in the amount
indicated above to be processed as an electronic funds transfer (EFT) or draft drawn from my checking or
savings account as indicated above and, if necessary, to have my account electronically credited to correct
erroneous debits. I understand that my payment will be processed within 1-2 banking days. If the payment
returns unpaid, I authorize you or your service provider to collect the payment and my state’s return item
fee and, if applicable, costs, by EFT(s) or draft(s) drawn from my account.
Click here to view your state’s returned
item fee and, if applicable, costs. I understand that this authorization will remain in full force and
effect until I notify you that I wish to revoke it by calling
and allow you reasonable opportunity to act on my notice. PLEASE PRINT A COPY OF THIS PAGE FOR YOUR RECORDS.
ALTERNATIVELY, CONTACT US AT TO LEARN HOW YOU CAN OBTAIN A
COPY.