ACH Payment Authorization Form for Single or Recurring

This is permission for recurring or single debits. As an authorized signor on the Depository Account presented, by completing and signing this form you give Bogard Press-BSSC permission to charge/debit your account for the amount indicated on or after the indicated date. This authorization is to remain in full force and effect until Bogard Press-BSSC has received written notification from me of its termination. **

Please complete the information below:

I First Name* Last Name* as an authorized signor Bogard Press-BSSC to charge/debit my account. These payments are for: Description of goods/services/on account* . My Account/ Invoice Number is .

Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Email

example@example.com

Frequency

Single Payment on account or OrderRepeating Quarter payments

Depository Bank

Type of account

CheckingSavings

Routing Number

Account Number

I acknowledge that a minimum Non-Sufficient Funds (NSF) fee of $25 may be charged by Bogard Press-BSSC to me in the event there are insufficient funds available at the time the ACH payment is submitted. I authorize Bogard Press-BSSC to charge/debit the account indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services/account/invoice described above. This authorization will remain in effect for the occurrences above. I certify that I am an authorized signor on this Depository Account.

Signature

Date

Bogard Press

4605 N. State Line Ave

Texarkana, TX 75503