Recurring Payment Authorization Form

Recurring Payment Authorization Form

Sign and complete this form to authorize Action Financial Services, LLC to make a debit from your checking or savings account listed below.

By signing this Recurring Payment Authorization Form, you certify that you have read the terms of the attached Disclosure and the payment arrangement and you authorize Action Financial Services, LLC to withdraw the payment amount identified below on the date you provide. Should you fail to return this signed authorization to our office prior to your second monthly scheduled payment, this arrangement will be cancelled and you will need to contact our office to enter into a new repayment plan.

You will be provided 2 copies of this authorization form. You will need to keep a copy for your records and fax the completed form to 541-664-4073 or scan the form then email to .

Please complete the information below:

I ____________________ authorize Action Financial Services to withdraw from the account option

(Full name)

you choose below for $_______________ on _________________.

(Amount) (Monthly due date)

Bank Account Billing Address _____________________ City, State, Zip________________________

Borrower Phone # _______________________ Borrower Email _____________________________

Debit Card

Electronic Check

Signature_______________________________ Date_____________________

Should you have any questions, please contact Action Financial Services at 888-253-4239.

This communication is from a debt collector. This is an attempt to collect a debt and any information obtained will be used for that purpose.

COPY FOR YOUR RECORDS