Payment Withdrawal Authorization Form
Credit/Debit Card Automatic Payment Withdrawal Authorization FormA. Borrower’s InformationFull 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 on Card: Mailing Address: City : State: Zip: Credit/Debit Card Number: Card Type:
Card Expiration Date: Card Verfication Code:
C. Automatic Withdrawal Frequency & Amount
Authorized withdrawal amount: Frequency:
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 plus a administrative fee. I understand that I am authorizing this card to be put on file on my loan account. I also understand that this card will be billed for my due payments.
Mailing Address:Kings Enterprises INC505 North Garden StColumbia, TN 38401
Credit/Debit Card Automatic PaymentWithdrawal Authorization FormAccount: OL-
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Document Name: Payment Withdrawal Authorization Form
Agree & Sign