Sign and complete this form to authorize Piccopay 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 acknowledge that the origination of Piccopay transactions to my account must comply with the provisions of U.S. law. I will not dispute Piccopay’s billing with my bank so long as the transaction corresponds to the terms indicated in this agreement.