I certify that I am an authorized signer for the account indicated above and that I have the authority to authorize this/these transactions. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted transaction date, and that I will have limited time to report and dispute errors. In the case the transaction is returned for Non Sufficient Funds (NSF) I understand that Jack L. Koch Jr., M.D., PLLC may at its discretion attempt to process the charge again within 30 days, and agrees to an additional $10.00 charge for each attempt returned NSF, which will be initiated as a separate transaction from the authorized payment. I have certified that the above bank account is enabled for ACH transactions, and agree to reimburse Jack L. Koch Jr., M.D., PLLC all penalties and fees incurred as a result of my bank rejecting ACH debits or credits as a result of the account not being properly configured for ACH transactions. Both parties agree to be bound by NACHA Operating Rules as they pertain to this transaction. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I agree not to dispute this transaction with my bank provided the transaction corresponds to the terms indicated in this authorization form.