Authorization for Automatic Credit/Debit Card Payment

Authorization for Automatic Credit/Debit Card Payment
Customer Name *

First Name Last Name
Loan number *
Last four of Social Security number *
Cardholder Name *

First Name Last Name
Type of Card *
Billing Address *

Street Address

Street Address Line 2

City State

Zip Code
Agreement Terms and Conditions *

By signing below, you authorize Sullivan Motors / Mid-Atlantic Auto Finance to process recurring debit entries from credit/debit card identified above in accordance with the payment schedule on your account. Your payment will be made automatically from your designated account. If your due date falls on a weekend or holiday, your payment will still be processed on the payment due date. If a charge has been initially declined, you authorize us to attempt to re-charge the card at a later date up to (3) three times. You may cancel this authorization by providing written notice or by completing a new copy of this form with a new card. Notice of cancellation must be received at least forty eight (48) hours prior to the payment due date or payoff of the contract. For inquiries about credit card transactions or your account with us, please call (609)861-0045. Electronic Signature Agreement. By selecting this box, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting this box, you consent to be legally bound by this Agreement's terms and conditions.
Date

Month Day Year
Date
Customer Signature *

Clear
Should be Empty: