PLEASE READ THE FOLLOWING CAREFULLY!!!!!
I understand that this is an attempt to collect a debt and any information obtained will be used for that purpose
1. I certify that I am authorized to initiate transactions on this account.
2. I further acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law.
3. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted transaction date.
4. I understand that cancellations must be made in writing and I will not dispute so long as the amount corresponds to the terms indicated in this contract.
5. I agree to notify Clontz & Clontz, PLLC in writing of any changes in my account information or of my decision to terminate this authorization at least 15 days prior to the next due date of the charges.
6. I understand that written cancellations must be made in writing but can be made to firstname.lastname@example.org, by fax (704-376-2746) or in the regular mail to 225 South McDowell Street, Charlotte, NC 28204.
DO NOT ATTEMPT TO CANCEL A CHARGE BY TELEPHONE
Note to Third Party Payers (Non-Debtor Payers):
If payment is being made by someone other than a party to this account (Non-Debtor), the Debtor hereby authorizes Clontz & Clontz, PLLC to communicate with the third party making this payment. If payment is being made by a Non-Debtor, the Third Party Non-Debtor hereby authorizes Clontz & Clontz, PLLC to charge his/her credit card as set forth above.
You will need your file# or Name on Account to proceed with payment
Payment will be accepted by E-Check Only at this time
By clicking below to continue with a payment, you are agreeing to the above terms