By checking this box, I authorize [Client Name] hereinafter named COMPANY to initiate the number of automatic payments entered above as an ACH/electronic debit to my account entered above in the amount entered above starting on the date entered above.

I understand that this authorization will remain in full force and effect until I notify COMPANY by changing my preferences within Pay Portal that I wish to revoke this authorization. I understand that COMPANY needs to be notified of my cancellation before 8pm CT in order to process my request the same day. I understand if I notify COMPANY of my cancellation after 8pm CT, it will require one business day to process my request.

I understand that payments submitted after 8pm CT will be processed the next business day. I understand that payments falling on a Saturday, Sunday, or Federal Bank holiday will be processed the following Monday.

I agree that ACH transactions I authorize comply with all applicable law.

It is recommended that you print a copy of this authorization and maintain it for your records.