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

Client Name: *

Billing Street Address: *

City *

State *

Zip Code *

Phone Number: *

Email:

Payment Type: *

E-Check

Credit Card

Payment Frequency: *

one-time payment

recurring monthly payment

to be debited on this date each month: *

ACH Debit Details

I authorize Kidwell & Associates to debit my bank account in the amount of: *

Account Type: *

Checking

Savings

Bank Name: *

Routing Number: *

Account Number: *

Credit Card Details

I authorize Kidwell & Associates to charge my credit/debit card in the amount of: *

Credit Card Type *

Name on Card *

Credit Card Number *

Expiration Date (mm/yy) *

CVV: *

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 I understand that debits to the account are electronic transactions and funds may be withdrawn from the account as soon as the date of my authorization.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. *

clear

Date Signed: * +