I __________ authorize OfficeName to initiate the below one time transaction against the debit card account below. This authorization is to remain in full force and effect until any and all accounts associated with the customer name below are paid in full, or until I notify OfficeName in writing of my intent to cancel and/or rescind this authorization in such time as to afford OfficeName and the financial institution as a reasonable opportunity to act on it.

Amount: $MinDue

Date: CurrentDate

I __________ authorize OfficeName to initiate the below transaction(s) against the credit / debit card account below. I acknowledge this is pre-authorization to process the credit / debit card payment(s) outlined below. This authorization is to remain in full force and effect until any and all accounts associated with the customer name above are paid in full, or until I notify OfficeName in writing of my intent to cancel and/or rescind this authorization in such time as to afford OfficeName and the financial institution a reasonable opportunity to act on it. In the event that an attempted credit / debit transaction is unsuccessful, I hereby authorize OfficeName to re-attempt the transaction within 15 days of the original payment due date.

Set Amount: $MinDue

One Time Transaction Date: CurrentDate

I __________ authorize OfficeName to initiate the below transaction(s) against the credit / debit card account below, according to the payment schedule listed herein. I acknowledge this is pre-authorization to process the credit / debit card payments outlined below. This authorization is to remain in full force and effect until any and all accounts associated with the customer name above are paid in full, or until I notify OfficeName in writing of my intent to cancel and/or rescind this authorization in such time as to afford OfficeName and the financial instituation a reasonable opportunity to act on it. In the event that an attempted credit / debit transaction is unsuccessful, I hereby authorize OfficeName to re-attempt the transaction within 15 days of the original payment due date.

For an amount between: $1.00 (minimum recurring payment) and $AmountBetween (total amount due).

Recurring Transaction Basis: Payment dates based upon the payment schedule of the attached contract.