Recurring Payment Plan Authorization Form printable pdf download

Recurring Payment Plan Authorization Form

Bank Account or Credit Card

Schedule your payment to be automatically deducted from your checking account, or charged to your

Visa, MasterCard, American Express or Discover Card.

The Recurring Payment Plan will help you in several ways:



It’s convenient (saving you time and postage)



Your payment is always on time (even if you’re out of town), eliminating late charges



It’s easy to sign up

Here’s how the Recurring Payment Plan works:

You authorize regularly scheduled charges to your checking/savings account or credit card. You will

be charged each billing period the total amount due for that period. A receipt of payment will be

emailed to you and will appear on your statement.

Please complete the information below:

I ____________________________ authorize SSC Parking to charge/debit my

(name)

account on the

First

of each month for payment of my bill.

(date of transaction)

Billing Address ____________________________

Phone# ________________________

City, State, Zip ____________________________

Checking/ Savings Account

Credit Card

Visa

MasterCard

Checking

Savings

Name on Acct

____________________

Amex

Discover

Bank Name

____________________

Cardholder Name _________________________

Account Number ____________________

Account Number

_________________________

Bank Routing #

____________________

Exp. Date

____________

Bank City/State

____________________

CVV (3 digit number on back of card) ______

SIGNATURE

DATE

I agree to notify the business in writing of any changes in my account information or termination of this authorization 15 days prior to the next

due date of the charges. For ACH debits to my checking/savings account, I understand that because this is an electronic transaction, these

funds may be withdrawn from my account each month as soon as the above noted transaction date. I acknowledge that the origination of

ACH transactions to my account must comply with the provisions of U.S. law. I will not dispute the company’s recurring billing with my bank

or credit card company; so long as the transaction corresponds to the terms indicated in this agreement.

Recurring Payment Plan Authorization Form

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