By clicking Submit I hereby authorize (Business Name or Entity) to initiate (monthly, weekly, quarterly , or annual) electronic debit withdrawals from the indicated bank account for payments in the amount of (Amount) (or as they become due and payable under the terms and conditions of the agreement) and as described herein.

The first payment will be withdrawn from your bank on (Month / Day) or (the following business banking day), then, (Number) subsequent payments (on the (Day of each (Month or other specified cycle))) for the duration of this authorization and term of your (Agreement, subscription, service plan, payment plan, etc). I understand that if this transaction is submitted after 6:00 PM Eastern Standard Time, it will have an effective date of no sooner than the next business-banking day and will show as a withdrawal from my account on that date. If I wish to rescind this authorization and cancel this payment, or the amount withdrawn from my account is different than the amount authorized herein, I may call (Customer Service Number) during the following business hours (Mon-Friday, 8am - 5pm CST). Furthermore, I assert that I am the owner or an authorized signer of the bank account provided.