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METHOD:

CARD NUMBER:

EXPIRATION DATE:

PAYMENT AMOUNT:

CONVENIENCE FEE:

TOTAL PAYMENT AMOUNT:

I authorize a one-time payment in the amount of from the card information specified above on .

METHOD:

ACH

BANK ACCOUNT NUMBER:

ROUTING NUMBER:

PAYMENT AMOUNT:

CONVENIENCE FEE:

TOTAL PAYMENT AMOUNT:

I authorize a one-time ACH debit in the amount of from the bank account specified above on . I understand that this payment authorization may not be revoked after I click the “Authorize” button below.

METHOD (CAD):

ACH

BANK ACCOUNT NUMBER:

ROUTING NUMBER:

ACCOUNT TYPE:

PAYMENT AMOUNT:

CONVENIENCE FEE:

TOTAL PAYMENT AMOUNT:

{{Canada.Name}} has been contracted by {{CompanyName}}. You, the Payor, authorize {{Canada.Name}} to debit the bank account identified above for {{TotalPaymentAmount}} on {{CurrentDate}} or the next business day. {{Canada.Name}} may appear in the Payor’s bank statement. You, the Payor, confirm that you have authority under the terms of the account agreement to authorize this debit.

This authority is to remain in effect until the one-time payment is complete, at which time the agreement will automatically terminate.

This agreement may be cancelled provided notice is received 5 days before the One-Time Payment Date. If any of the above details are incorrect, please contact us immediately at {{USA.Phone}} or {{HelpEmail}}. If the details are correct, no further action is required. The One-Time Pre-Authorized Debit (PAD) will be processed on the One-Time Payment Date indicated above.

You, the Payor, have certain recourse rights if any debit does not comply with this agreement. For example, you have the right to receive reimbursement for any debit that is not authorized or is not consistent with this PAD Agreement. To obtain more information on your recourse rights, contact your financial institution or visit www.payments.ca.

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