To automatically debit my	checking	savings account	_____________________________
			Number

I understand that this authorization will be in effect until I notify my financial institution in writing that I no longer desire this service, allowing it reasonable time to act on my notification. I also understand that if corrections in the debit amount are necessary, it may involve an adjustment (credit or debit) to my account.

I have the right to stop payment of a debit entry by notifying my financial institution before the account is charged. If an erroneous debit entry is charged against my account, I have the right to have the amount of the entry credited to my account by my financial institution, if, within 15 days following the date on which I was sent a statement of account or a written notice of such entry or 45 days after posting, whichever occurs first, I give my financial institution a written notice identifying the entry, stating that it is in error and requesting credit back to my account.

This authorization is non-negotiable and non-transferable.

_________________________________ Customer Name (please print)		___________________________________  Customer ID Number
_________________________________ Signature		___________________________________  Date
_________________________________ Phone Number		___________________________________ Email Address