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ACH Recurring Payment Authorization Form
Schedule your payment to be automatically deducted from your checking or savings account. Just complete and sign this form to get started!
Recurring Payments Will Make Your Life Easier:
* It’s convenient (saving you time and postage)
* Your payment is always on time (even if you’re out of town), eliminating late charges
Here’s How Recurring Payments Work:
You authorize regularly scheduled charges to your checking or savings account. You will be charged the amount indicated below each billing period. A receipt for each payment will be emailed to you and the charge will appear on your bank statement as an “ACH Debit.” You agree that no prior-notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected.
PLEASE COMPLETE THE INFORMATION BELOW:
I authorize
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Choose Company
125 Perry LLC.
Park Right Corp.
Prion Corp.
Empire Parking Corp.
West 43 parking LLC.
East 29 Parking LLC.
180 Orchard Parking LLC.
Gold Street LLC.
STRELLA LLC
Linden Parking
1 West St. ( Ocean Garage)
to charge my bank account indicated below on the 1st of each month for payment of my Monthly Parking Fee.
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First
Last
Monthly Number
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Billing Address
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Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Phone
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Email
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Account Type
Checking
Savings
Name on Account
*
Bank Name
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Account Number
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Bank Routing #
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Bank City/State
*
Signature
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First
Last
I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted periodic payment dates fall on a weekend or holiday, I understand that the payment may be executed on the next business day. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that may at its discretion attempt to process the charge again within 30 days, and agree to an additional $25 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I agree not to dispute this recurring billing with my bank so long as the transactions correspond to the terms indicated in this authorization form.
Date Time
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