TEST 02/22

/TEST 02/22
TEST 02/222018-02-22T22:39:17+00:00


  • Credit Card Recurring Payment Authorization Form

  • Schedule your payments to be automatically deducted from your bank account or charged to your Visa, MasterCard or American Express card. Just complete and sign this form to get started!
  • Here’s How Recurring Payments Work:
  • You authorize regularly scheduled charges to your checking/savings account or credit card. You will be charged the amount indicated below at the start of each billing period. A receipt will be emailed to you and each charge will appear on your statement as “Jaymie Scotto & Assoc”. You agree that no prior notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected.
  • Customer Information

  • Checking / Savings Account

  • P.O. Box 20, Middlebrook, VA 24459 | 866.695.3629 | www.jsa.net Confidential – All Rights Reserved. © Jaymie Scotto Associates
  • American Express
  • I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Jaymie Scotto & Associates in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that Jaymie Scotto & Associates may at its discretion attempt to process the charge again within 30 days, and agree to an additional $40.00 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated in this authorization form.