HCI Electronic Rental Payment Authorization Form - Haul-Mor Logo
  • ELECTRONIC RENTAL PAYMENT AUTHORIZATION FORM

  • Heartland Capital Investments, LLC

    PO Box 409 Mayfield, KY 42066 | (270) 247-3199 | www.hci.net

  • Contact / Billing Information

  • Payment Plan

  • Banking Information

  • Banking Information

  • Rental Payment Authorization

  • By signing below. I authorize Heartland Capital Investments, LLC (the "Company") and its agent to debit my account as follows. This authorization shall remain in effect until I notify Company that I wish to revoke it, I terminate the transaction. or I exercise my rights to acquire ownership as provided in the Rental Purchase Agreement I agree to give at least 3 business days' notice to cancel this authorization by calling Company at 270-247-3199. I authorize Company to debit funds out of my account on or after the date listed, at the frequency shown. I agree that the debits may be between the amount listed +/- any change in my applicable taxes. I authorize Company to debit or credit my account to correct erroneous debit, credit, bank, routing. or account information. If my payment is returned NSF. I authorize Company to debit my account to collect any fee provided for in the Agreement. Company will only debit the account once for each scheduled payment that is returned NSF. I understand that I am required to pay any NSF (or other) fees charged by my bank. I represent and warrant that I am authorized to execute this payment authorization. I hereby indemnify and hold the Company and its agent harmless from damage, loss, or claim resulting from all authorized actions hereunder. Fee Disclosure: If paying Agreement calculated payment amount then a $3.00 flat rate is added per transaction. If paying more than the Agreement calculated payment amount then a 3% rate is added per transaction.

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