Invoice Number101 East Center St., Rochester, MN 55904 Personal InformationName:* First Middle Last Address*All fields are required. 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If so select "Yes" to enter in a dollar amount.The default is "No"YesNoDeposit, Pro-rated, or OtherEnter your deposit, pro-rated, or another amount. 3.5% of transaction will be applied to cover processing fees. Price: $0.00 Total $0.00 Payment Options* Credit Card eCheck Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Security Code Cardholder Name eCheck*United States accounts only for ACH or eCheck* Name on Account Bank Name Routing Number Account Number CheckingSavingsAccount Type I (we) hereby authorize Resident Property Management, hereinafter called COMPANY, to initiate debit entries, including, but not limited to, recurring transactions, to my (our) Checking Account / Savings Account and/or Credit or Debit Card, and if necessary make any adjustments via credit entries for any erroneous debit, indicated below at the depository financial institution named, hereafter called DEPOSITORY. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law. The authorization is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (ACH DEBITS and CREDIT OR DEBIT CARD DEBITS)* YES, I AGREE TO THE PAYMENT TERMS CAPTCHASecurity CheckThe Submit button will appear when all required fields are completed. And filed with a red * is a required field please make sure you did not miss one. Δ
