iPlanGroup - Expense Payment Authorization Form

Expense Payment Authorization Form

Use this form to pay for an expense related to an asset held in your account.
Account Owner Information
iPlanGroup Account Number*
Account Owner Name*

First NameLast Name
Please verify the last 4 of your SSN*

Asset and Expense Information

Please describe the asset that you are looking to make a payment for.
Asset / Investment Description*
Description of Expense Payment Category*
Information to be Referenced on Payment (Account Number, Parcel Number, etc.)

0/50
Please provide a copy of the invoice or third-party payment receipt corresponding to this expense request.

Cancelof
FREQUENCY OF PAYMENT

Tell us how often to process this expense.
Is this a one time payment, or a recurring expense?*

One Time PaymentRecurring Payment
How often would you like us to process this request?*

MonthlyQuarterlyYearly
When would you like us to submit this payment? *

MonthDayYear
Date

Expense Payment Instructions

Please tell us how you would like us to send the funds.
How would you like us to send the funds?*

CheckWire (fees apply)ACH (fees apply)
Would you prefer a Regular Check or a Cashier's Check?*

Regular CheckCashier's Check (fees apply)
How should we deliver the check?*

Regular MailOvernight Mail (fees apply)Pickup at iPlanGroup Location
Who should we make the check payable to? *
Total Payment Amount for Expense*
Please tell us how much the Expense is.
Check Delivery Instructions*

Company/Person

Address

CityState

Zip Code
Bank Account Type*
Total Payment Amount to be Sent*
Wire/ACH Instructions*

Bank Name

Bank Account Name

ABA Routing NumberState / Province

Bank Account Number
Bank Address

Street Address

Street Address Line 2

CityState

Zip Code

Processing of Fees For Expense Payment
Please Indicate below how you would like to pay for any fees associated with this transaction.*

Debit Fees From My AccountMail a CheckPay with Debit/Credit Card
Note : After form submission, you will receive an online payment link via the E-mail address that we have on file for your account.
Account Owner Authorization and Signature

Please read the following, then sign and date.
Account Owner Signature*

Clear
Date*

MonthDayYear
Date
Expense Amount Calculation
Should be Empty:

Expense Payment Authorization Form