Authorization of Payment
Automatic Billing
Name:
Address:
City:
State:
Zip
Email:
Bank Name
Account Type
Please Select
Checking
Savings
Routing Number
Account Number
Acknowledgement
By submitting this form, 1) I authorize Homewatch CareGivers of Boca Raton to debit my ACH account for the amount indicated on my invoice or for any amount owed upon client expiration or contract termination. 2) I represent and warrant that I am authorized to execute this payment authorization for the purpose of implementing this payment plan with Homewatch CareGivers of Boca Raton. 3) I indemnify and hold Homewatch CareGivers of Boca Raton and/or my bank harmless from damage, loss or claim resulting from all authorized actions hereunder. 4) I understand that this payment plan may be cancelled by Homewatch CareGivers of Boca Raton and/or the bank due to NSF (Non-Sufficient Funds) and that I am liable to pay an NSF fee of $150.00 (or the amount allowable by law), which may be automatically debited for each NSF.
Validation
