Draft My Bank Account 

*Name on Checking Account: 
*Address: 
Address 2: 
*City:   ** *
*Phone (xxx-xxx-xxxx): 
*Name of Your Bank: 
*Bank Routing #: 
The routing # is nine digits and appears as xxxxxxxxx
*Bank Acct. Number: 
The account # appears as xxxxxxx
(do not include numbers following the )

*Enter Payment Amount: 

 $   Check #
This is a one time payment
Please deduct this same amount from my account every month on the day of each month.
(I understand I can cancel at any time.)

 


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