Cuzima Care LLC – Payment Authorization Form

Payment Details
Payment Method:*

Credit/Debit Card (Processed via Stripe)ACH Bank Transfer (Manual Processing)Other
Payment Frequency:
Total Authorized Amount:
$
Payment Start Date:

MonthDayYear
Date

Authorization & Agreement
IFull Name* , authorize Cuzima Care LLC to charge my selected payment method for services rendered.
I understand that:
✅ Payments will be processed as per the agreed schedule.
✅ Any cancellations must be made in writing at least 7 days before the next billing cycle.
✅ Any declined payments may result in a late fee or service interruption.
✅ My personal and financial information will be securely processed and stored in compliance with PCI-DSS regulations.
Client Signature*

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Date

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Date
Cuzima Care Representative Signature:

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Date

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Date
Should be Empty:

Payment Details