AUTO PAY PROGRAM
(AUTHORIZATION TO DEBIT AND CREDIT ACCOUNT BY ACH)
 

 

Please allow 5 business days for your ACH payment request to process.

Customer Name:
Contract Number:
Bank Name:   ABA/Routing Number:
Bank Branch:   Account Name:
City:   Account Number:
State:   Zip:


The check number is on the top and bottom right of the check - we do not need the check number.
Account Number is the middle group of 12 numbers on the bottom of your check.
Routing Number is the group of 9 numbers on the bottom left of your check.

  Customer Contact Information (if different from information below):
  Name:
  Title:
  Phone Number:
  E-mail Address:
 REQUIRED CUSTOMER AUTHORIZATION:
  Name of person making
  authorization on behalf of Customer:
  Title:
  Phone Number:
  E-mail Address:
In connection with the above referenced contract(s) ("Contract"), Customer(s) hereby authorize, Administration Services AND/OR ITS AGENTS, SUCCESSORS AND ASSIGNS (collectively, "Company"), to initiate ACH credit and/or debit entries, and if necessary, adjust any credit and/or debit entries made in error to the account described below ("Account") at the financial institution named below ("Bank"). The authorization provided herein (this "Authorization") is intended to encompass all amounts due and to become due under the above Contract, including current and past due periodic payments, miscellaneous charges, taxes and late charges. This Authorization shall not be limited or deemed waived, nor shall Company assume any liability, if for any reason Company delays debiting the Account for amounts due under the Contract. FOR ADMINISTRATIVE PURPOSES, ALL DEBIT AND CREDIT ENTRIES SHALL APPEAR ON THE ACCOUNT AS BEING INITIATED BY "LEASE SERVICES."

Customer certifies that all information set forth above is true and correct. Customer agrees to give Company not less than twenty (20) days advance written notification of any termination or change in this Authorization, which shall remain in full force and effect until Company has received such written notification from Customer.

Customer hereby acknowledges and agrees that the financial accommodations and periodic payments under the Contract have been agreed to by Company upon the condition that Company will be able to realize cost savings by administering the Contract using ACH debit and credit entries as authorized herein. If, for any reason, this Authorization is terminated or suspended or the Company is unable to administer the Contract by ACH debit and credit entries as authorized herein, Customer agrees that the periodic payments under the Contract may be increased by two percent (2%) until Company’s ability to administer the Contract by ACH debit and credit entries as authorized herein has been restored to the reasonable satisfaction of Company.

If you want to apply for ACH by fax, click here for the downloadable PDF.
CUSTOMER HEREBY AGREES TO THE TERMS AND CONDITIONS SET FORTH ABOVE. BY CLICKING THIS BOX, YOU AFFIRM THAT YOU ARE THE ABOVE NAMED PERSON AND THAT YOU ARE A DULY AUTHORIZED CORPORATE OFFICER OR OFFICIAL, PARTNER OR PROPRIETOR OF THE ABOVE NAMED CUSTOMER WITH THE POWER AND AUTHORITY TO AGREE ON BEHALF OF THE CUSTOMER TO THE ABOVE TERMS AND CONDITIONS.