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Debt Authorization Form

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  • I (we) hereby authorize The Wilson Agency, hereinafter called the Company, to initiate a debit entry to entries to the account indicated below at the depository financial institution named below, hereinafter called the Bank. This form authorizes the Bank holding the account to post all such entries. If this item is returned unpaid, I understand that a returned check fee will be applied to my account and additional fees could be charged by the Bank.
  • Bank Information

  • Other payment methods: Check, Money Order, Mail, Drop Box, Monthly PayPal
  • For recurring monthly debits, each debit will be processed on the fifth business day of each month. This authorization will remain in full force and effect until the Company has received written notification of its termination, in such time and manner as to afford the Company and the Bank a reasonable opportunity to act upon it.