Credit/Debit Card Automatic Payment Withdrawal Authorization Form for Co-borrowersA. Borrower’s Information – Full Name:
B. Billing Information (Credit/Debit Cards) – Please complete this section if you have chosen to have your payments automatically processed via Credit/Debit cards each periodName as it appears on card: Billing Address: City : State: Zip: Card Options: MasterCard, Visa, Discover and American Express
Credit/Debit Card Number (no spaces): Card Expiration Date: Card Verfication Code:
C. Automatic Withdrawal Frequency & Amount
Authorized withdrawal amount: Frequency: Starting Date(s)
I Authorize Kings Enterprises INC to automatically process payments and late fees from my above listed Credit /Debit Card on the frequency and dates selected in section C. I understand that I am authorizing this card to be put on file on a loan account in the name of NAME. I also understand that this card will be billed for the due payments for this account.
Mailing Address:Kings Enterprises INC505 North Garden StColumbia, TN 38401
Credit/Debit Card Automatic PaymentWithdrawal Authorization FormAccount: OL-
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Document Name: Co-borrower's Authorization
Agree & Sign