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payment authorization
LYNX LEGAL SERVICE Authorization agreement for pre-arranged payments (ACH)
I hereby authorize Lynx Legal Service , hereinafter called company, to electronically debit the account indicated below, and if necessary, electronically credit the account.
payment type
Debit: Debit is for a single one-time entry or:
Recurring: Recurring entries that reoccur at regular intervals without any affirmative action required to initiate future entries.
Type of account
Checking
Savings
Bank Name
Routing Number
Bank Account Number
First Payment Amount
on {Date}
MM slash DD slash YYYY
Subsequent Payment Amount
Number of Payments
Please enter a number from
1
to
10
.
Total amount of all payments.
Subsequent payments to be debited every ( ? ) days from date of First Payment, until total above is paid
Please enter a number from
1
to
31
.
Type Name to sign
First
Last
Email
Date
MM slash DD slash YYYY
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