Payment Authorization Form

  • The Account Holder identified below, hereby authorizes Weekes Law Office, PC to debit my account identified below in the amount indicated below for each billing period (on the monthly anniversary of the date set forth below) until the balance owed to Weekes Law Office, PC is paid in full or I otherwise revoke this authorization in writing. I agree that no prior-notification will be provided to me prior to withdrawal hereunder. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Weekes Law Office, PC in writing of any changes in the account information or termination of this authorization at least 7 days prior to the next scheduled billing date. I understand that a payment that is scheduled falls on a weekend or holiday, the payment may be processed on that date or on the next business day. I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. I understand and agree that a $25 late fee will be assessed for any payment not received on or before the applicable due date. I understand that Weekes Law, LLC may at its discretion attempt to process the charge again within 3 days up to three times. You agree that a card service fee of three percent (3%) of the transaction amount may be billed in addition to the scheduled amount. I certify that I am an authorized user of the provided card and will not dispute these scheduled transactions with my card company, so long as the transactions correspond to the terms indicated in this authorization form. I understand that it is the client's responsibility to ensure that the monthly amount meets the payment term requirement contained in the applicable agreement.
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  • I hereby authorize Weekes Law, LLC to charge my bank account and/or debit card the Minimum Monthly Amount as required by my agreement with Weekes Law beginning on the Commencement Date and then periodically according to the Payment Frequency listed herein, until the balance is paid in full.
  • By typing your name below you are signing and assenting to this agreement.
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