Authorization for Recurring Debit via ACH

An Automated Clearing House (ACH) authorization is a payment authorization that gives the merchant permission to electronically debit money from a consumer’s account when a payment is due.

Payments will come from the depository financial institution named below (“DEPOSITORY”). I (we) agree that ACH transactions I (we) authorize comply with all applicable law.

Payments will be on the 10th day of each month beginning on the starting date, through the ending date.

Select One:

Checking Account

Savings Account

Depository Name:

Routing Number:

Account Number:

Name(s) on the Account:

Signer's Name:

Starting Date:

(month/year)

Ending Date:

(month/year)

Date

YYYY

I (we) understand that this authorization will remain in full force and effect until I (we) notify Scapes Inc. in writing to P.O Box 99, Harwood, MD. 20776, that I (we) wish to revoke this authorization. I (we) understand that Scapes Inc. requires at least one month prior notice in order to cancel this authorization.

I accept