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One Time Payment Authorization

Payment Authorization
You agree to the following pre-authorized checking withdrawal agreement with Whitfield & Associates LLC:

Purpose for the Payment:

Payment Amount: $ from your bank account.

You hereby authorize Whitfield & Associates LLC to initiate debit entries to the bank account indicated below.

Enter your name or your company's name, address and account information as shown on your bank account.

Your Name or Company's Name:

Your Address or Company's Address:

City, State and Zip Code:

Bank Routing Number:

Account Number:

I have double-checked my bank account information and confirm it is correct.

Your Daytime or Mobile Phone:

By signing this form, I understand I waive my right to receive additional prior notice of the deduction indicated above. I also authorize a $30.00 service charge for returned unpaid drafts from my bank. I agree to the above-marked automatic checking debit and will abide by any charge that is accrued for insufficient funds.

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Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

December 23, 2022 8:46 pm CST

One Time Payment Authorization Uploaded by Belinda Whitfield - support@churchcpa.com IP 67.162.21.175

July 21, 2023 6:59 am CST

Billing Department - billing@churchcpa.com added by Belinda Whitfield - support@churchcpa.com as a CC'd Recipient Ip: 40.138.137.183