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:

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.