eCheck Authorization

First Name *

Last Name *

Street Address * 🛈

City *

State *

Zip Code *

Phone Number *

Email Address *

Email a receipt? *

Yes

No

Routing Number *

Account Number *

Check Number

Bank Name *

Bank Location (City & State) *

Authorization Method:

Signature

Type Name

I hereby authorize Take Charge Credit Consulting LLC to initiate entries (via ACH or RCC) to my checking account at the financial institution listed above, and, if necessary, initiate adjustments for any transactions credited/debited in error, pursuant to the terms and fees outlined in my contract or service agreement. This authority shall remain in effect until Take Charge Credit Consulting LLC is notified by me in writing to cancel it in such time as to afford Take Charge Credit Consulting LLC and its' payment processing provider(s) reasonable opportunity to act on it.

Authorized Account Holder: *

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