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Account Details |
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| Office Account Number: | %wdsAcctNumber% |
| Reference Number: | %referenceNumber% |
| Payment Method: | %paymentMethod% |
| Cardholder's Name: | %acctName% |
| %cardNumberLbl%: | %cardNumber% |
| Routing Number: | %routingNumber% |
| Billing Zip Code: | %acctZipCode% |
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Down Payment Details |
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| Total down payments : $%downpaymentBalance% | |
| Down Payment 1 Amount: $ %downOneAmount% | Down Payment 1 Date: %downOneDate% |
| Down Payment 2 Amount: $ %downTwoAmount% | Down Payment 2 Date: %downTwoDate% |
| Down Payment 3 Amount: $ %downThreeAmount% | Down Payment 3 Date: %downThreeDate% |
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Recurring and Final Payment Details |
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| Recurring Payment Amount: | $ %recurringPaymentAmount%. Please note that this amount may change, including if you enter into a new contract and/or we provide additional services. The new amount and any change in the debiting date will be set forth in the contract or other document evidencing each such change and/or in your billing statements. |
| Transaction Start Date: | %recurringDate% |
| Frequency: | %recurringFrequency% |
| Number of Payments: | %recurringNumberOfPayments% |
| Final Projected Amount: | $ %finalProjectedAmount% |
| Final Projected Date: | %finalProjectedDate% |
By signing below, I warrant that I am an authorized user of the account identified above. I authorize %receiptCompanyNameFull% or an affiliated entity or vendor to validate and verify the account identified above and initiate debits or charges to the deposit/credit/debit card account identified above in the amounts and on the dates and number of times described above. I acknowledge that the origination of ACH transactions to my deposit account must comply with the provisions of all applicable laws. I agree and understand that any changes to my account information or termination of this authorization must be submitted in writing to Attn: Project Specialist at P.O. Box 14228, Orange, CA, 92863 and must be received by %receiptCompanyName% at least 15 days prior to the next due date of the payment. If I terminate this Auto Payment Authorization, I acknowledge that I will still be fully obligated to make each of my payments to %receiptCompanyName% by check or other means on or before each due date. I acknowledge that any payment debits/charges made by %receiptCompanyName% will appear as “%receiptCompanyNameDBA%” on my statement.
By signing below, I agree that the total payment amount, installment payment amounts and the number of payments outlined above reflect the terms of the new and/or revised Service and Installment Agreement that I entered into on or about %currdate%.
I understand that should a debit not be honored by my bank, I will incur a service charge imposed by %receiptCompanyName% of up to $25 for each such dishonored debit. I acknowledge that my bank may also impose a fee for a dishonored debit. Further, I acknowledge that any debit or charge not honored will result in a default on a payment installment owing under my services contract with %receiptCompanyName%, and may subject me to late fees and other remedies of %receiptCompanyName% as set forth in my Service and Installment Contract.
I authorize %receiptCompanyName% to charge or make electronic fund transfers from my account identified above to collect each of the following fees when assessed and without further notice:
(1) Broken appointment fee at $%metalBracketPrice% each
(2) Broken bracket fee:
A. Metal bracket at $40.00 each
B. Clear or gold bracket at $%goldBracketPrice% each
(3). %lateFeeMsg%
Only payments made and received before 3:00 PM PST will be applied to an account on the same day.
I acknowledge that I should keep my copy of this Auto Payment Authorization for my records.