Payment Authorization Agreement

This information is confidential and will only be kept by Kidwell & Associates Finance Department.

Ensure that all fields have been filled in correctly.

Client Information

Payment Type: *
Payment Frequency: *

ACH Debit Details

Account Type: *

Credit Card Details

I hereby authorize Kidwell & Associates to initiate a debit to the account/card listed above. I understand that debits to the account are electronic transactions and funds may be withdrawn from the account as soon as the date of my authorization. I certify that I am an authorized user of this bank account/ card and will not dispute these scheduled transactions with my bank or credit card company as long as the transactions correspond to the terms indicated in this authorization form. In the case of a transaction being rejected for Non-Sufficient Funds (NSF), I understand that Kidwell & Associates may attempt to process the charge again within 3 days, and I agree to an additional $30.00 NSF fee. *