I hereby authorize Liquid Payments (LQpay), on behalf of Orthodontic Associates (OA), to initiate debit entries to the account indicated below via electronic funds transfer (EFT). I hereby authorize the financial institution named below to accept and honor EFT withdrawals by LQpay.

I understand that in accordance to my financial arrangement with Orthodontic Associates, LQpay will begin withdrawals from my bank account. Such withdrawals will continue each month, on the agreed upon date, until the entire balance, provided to LQpay by OA, is paid in full. I understand that LQpay is debiting funds from my account for payment to OA and that the name Liquid Payments may/will appear on my monthly statement. I understand my final payment may be slightly more or less than the Monthly Payment Amount listed above, but will not exceed the balance of the account. Should OA need to reduce the amount of debit, OA may notify LQpay to reduce the Monthly Payment Amount without notification to me.

I further agree that should LQpay be notified that funds are not available in my bank account (NSF, closed account, etc.) a $20 fee will be charged by OA. I agree that if funds are not available from the account LQpay can re-draft my account. I understand that if I choose to discontinue this method of payment, I must notify OA, a minimum of 4 days prior to my scheduled debit date. Please note that drafts are initiated at approximately 5:30 am CST on the due date.

I certify that I am an authorized user of this bank account and will not dispute the scheduled transactions with my bank: provided the transactions correspond to the terms indicated on this authorization form.