ADT ACH 3rd Party Authorization Form

ADT monthly payment authorization form
ALARM ACCOUNT DETAILS
Name of person on the ADT alarm agreement (homeowner)*
Complete address where alarm system is located (including city/state/zip code)*
PAYMENT AUTHORIZATION DETAILS
Name of person making payments*
Email (person making the payments)*
example@example.com
Cell Number (person making the payments)*
Relationship to ADT alarm acct holder*
Type a question*

Checking/SavingsCredit/Debit Card (No prepaid cards)
Complete billing address - If different to premises where alarm system is located (affiliated to payment method). If same address, please type "NA"*
IF USING CHECK OR SAVING ACCT, PLEASE PROVIDE THE FOLLOWING
Name of Bank
Bank Acct
Routing (9 digit number)
IF USING CREDIT OR DEBIT CARD, PLEASE PROVIDE THE FOLLOWING
PAYMENT AUTHORIZATION STATEMENT - PLEASE READ
I do hereby acknowledge that the above information is correct and that I am the authorized user (cardholder/bank account holder) of said account. I authorize ADT/Smart Home Security to charge my account for monthly reoccurring alarm monitoring services for the above listed alarm monitoring address starting immediately. I understand that I am responsible to ensure that funds are available in the account to cover the monthly payments as set on the alarm monitoring agreement each month (plus tax where applicable I hereby authorize Smart Home Security to contact me (via text, email, call) regarding any payment issues. ADT DOES NOT ACCEPT PREPAID CARDS

For validation and security reasons a copy of d/l and billing account information must be loaded into our secured portal
VALIDATION DOCUMENTS - TO ENSURE YOUR SAFETY, THESE DOCUMENTS ARE REQUIRED FOR VERIFICATION AND SECURITY REASONS - THANK YOU
For authentication, please provide copy of ID, DL, or Passport. *

Cancelof
Signature*

Clear
Date*

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Date
Should be Empty:

ADT monthly payment authorization form

ALARM ACCOUNT DETAILS

PAYMENT AUTHORIZATION DETAILS

IF USING CHECK OR SAVING ACCT, PLEASE PROVIDE THE FOLLOWING

IF USING CREDIT OR DEBIT CARD, PLEASE PROVIDE THE FOLLOWING

PAYMENT AUTHORIZATION STATEMENT - PLEASE READ

VALIDATION DOCUMENTS - TO ENSURE YOUR SAFETY, THESE DOCUMENTS ARE REQUIRED FOR VERIFICATION AND SECURITY REASONS - THANK YOU