Debt Payment Plan Form

Recurring Credit Card Payment Authorization Form
Name*

First NameMiddle NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Debt Amount:*
The amount you owe can be found on the debt letter sent to your address and email.
Payment Amount:*
Minimum of $20
Payment Frequency*
Payment Start Date*

MonthDayYear
Would you like to be able to make other payments in addition to the recurring plan amount?*
EX: One time $50 payment in addition to the $75 weekly
Acknowledgment / Agreement
I understand that I will be charged the amount indicated each billing period, receipt for each payment will be provided and the charge will appear on my credit card statement. I understand that this is an automatic recurring charge process and no prior-notification will be provided before each charge.

I understand that this authorization will remain in effect until I cancel it in writing via email or paper.

I understand that I must notify in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date.

I understand if my card declines or i recieve a new credit card, that it is my repsonsibilty to notify the student services bookkeeper.

I understand that if I fault on this payment arrangement that I wil lose the ability to pay off the debt in installments.

I acknowledge that the origination of Credit Card transactions to my account must comply with the provisions of U.S. law.

I certify that I am an authorized user of this Credit Card and will not dispute these scheduled transactions; so long as the transactions correspond to the terms indicated in this authorization form.
By signing this form, I First Name* , am authorizing regularly scheduled charges to the credit/debit card provided from Tom P. Haney and agreeing to the all the terms listed above.
Signature*

Powered by Jotform SignClear
Date

MonthDayYear
Should be Empty:

Recurring Credit Card Payment Authorization Form

Acknowledgment / Agreement