QBME_Change Payment Method Sheet

Updated Payment Information
Legal Name of Organization
DBA Name (if applicable):
EIN Number:
e.g., 23
Current Mailing Address of Organization

Street Address

Street Address Line 2

CityState

Zip Code
Please select the option in which you would like your future payments to be processed: (Please be aware that credit card payments will be assessed a 3% processing fee at time of future payments)
Bank Name
Name(s) on Bank Account (business name if used)
Account Number
must be 9-12 numbers - no spaces
Routing Number
must be 9 numbers - no spaces
Type of Bank Account
Bank Phone Number
Format: (000) 000-0000.
Date

MonthDayYear
Date
First Name* Last Name* Date*
(Please enter the Client Name or Client Representative in the fields above)
Signature
Should be Empty:

Updated Payment Information