PREFERRED PAYMENT TERMS AND CONDITIONS
By completing this form, I authorize Middle Tree, its authorized representatives, and services provided to initiate electronic withdrawals from my designated account to make monthly payments on my contract for services. Should my preferred payment be declined, I authorize Middle Tree to process any other payment type on my account. I understand that I will receive confirmation specifying the date the electronic withdrawals will begin. I understand that I will continue
to make my payment until I receive this confirmation and electronic withdrawals begin. A copy of this agreement shall serve as notice. I understand that this authorization and the program services in no way alter or lessen my obligation under my existing Middle Tree contract regarding the amounts of monthly payments, when payments are due, the
application of payments, the assessment of late charges, or the determination of delinquencies. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or credit
card company so long as the transactions correspond to the terms indicated on this authorization form. I must maintain sufficient funds in my account for withdrawal of my payment amount. I understand that I must provide Middle Tree notice of at least 10 days for any request to modify, change, or terminate participation in this program. I agree to be bound by the Programs Terms and Conditions that are stated herein.