One Time Payment Authorization

General Information

Name*

Payment Amount**

Apartment*

Reason for Payment*

Reason for Payment, if Other*

Phone#*

City, State, Zip*

Email**

Billing Address*

Checking/Savings Account

Checking/Savings Account*

Name on Account*

Bank Name*

Bank City/State*

Account Number*

Bank Routing Number*

I understand that this authorization will remain in effect until the designated expiration date or until I cancel it in writing, whichever comes first, and I agree to notify Quad Investments, Inc. in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates falls on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that Quad Investments, Inc. may at its discretion attempt to process the charge again within 30 days, and agree to an additional $30 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and agree not to dispute these scheduled payments with my bank or credit card company; provided the transactions correspond to the terms indicated in this authorization form.

I authorize Quad Investments, Inc. to charge my account indicated above for this One Time Payment due.

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Applicant’s Electronic Signature**

Date*

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