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BANK AUTHORIZATION FORM
Bank Routing Number
Confirm Account Number
BURGOS & ASSOCIATES, INC. dba ACR ACCOUNTING & CONSULTING RESOURCES
to debit the bank account indicated above for the amount of
Two Hundred Fifty 00/100 Dollars***
plus any other charges due starting on 05/08/2020. This payment is for Professional Services described on the Service Agreement. I understand that this authorization will remain in effect until the schedule end date, or until I cancel it in writing, which ever comes first. That I will notify
in writing of any changes in my bank account information or termination of this authorization at least 30 days prior to the next billing date. If the above noted payment date falls on a weekend or holiday, the payment may be executed on the next business day. Because this is an electronic transaction, these funds may be withdrawn from my account each period as soon as the above noted transaction date. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that ACR may, at its discretion, attempt to process the charge again within 30 days, and agree to an additional $29.00 charge for each attempt returned NSF, which will be initiated as a separate transaction. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this bank account, and that I will not dispute the payment with my Bank, so long as the transaction corresponds to the terms indicated in this form.
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