Monthly ACH Debit Authorization

Business to Debit Account
Authorized Business Name
 Paul Dion CPA
Authorized Business Phone
 508-853-3292
Authorized Business Address
 22 West Street #6
City
 Millbury
State
 MA
Zip
 01527
Account Holder Information
Account Holder's Bank Information
Account Type:


Payment Information
Frequency:
   
 
 
 
  Frequency:
Authorization
By electronically submitting this form, I hereby authorize Paul Dion CPA to debit the bank account referenced herein. This authority will remain in effect until the payment(s) are completed as specified herein. If a payment is returned for any reason I acknowledge that I am subject to a rejected item fee of $25 or the maximum allowed by law.
By electronically submitting this form, I hereby authorize Paul Dion CPA to debit the bank account referenced herein. This authority will remain in effect until revoked in writing by the account holder. If the payment is returned for any reason I acknowledge that I am subject to a rejected item fee of $25 or the maximum amount allowed by law.
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