Sign and complete this form to authorize to make a one-time debit to your checking or savings account.

By signing this form you give us permission to debit your account for the amount indicated on or after the indicated date. This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account.

I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted transaction date. In the case of the payment being rejected for Non-Sufficient Funds (NSF) I understand that may at its discretion attempt to process the charge again within 30 days, and I agree to an additional $100 charge for each attempt returned NSF, which will be initiated as a separate transaction from the authorized payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I will not dispute ’s billing with my bank so long as the transaction corresponds to the terms indicated in this agreement.