Authorization for Payment

By signing this form, I am authorizing Evan Lemoine CPA LLC to initiate an electronic debit in the amount and frequency indicated from the bank account I designate below. I understand that this Authorization will remain in full force and effect until the transaction is cancelled by me by contacting Evan Lemoine CPA LLC at least 10 days in advance, or the ACH/electronic debit is processed from the designated account. I certify that (1) I am authorized to debit the bank account above and (2) that the ACH/electronic payment I am authorizing complies with all applicable laws.

Frequency Recurring ChargeOne-Time Charge

I authorize Evan Lemoine CPA LLC to charge my bank account $ Datemonthlyweeklybiweeklysemi-monthlyquarterlyannuallyonce.

If recurring, these charges will end upon notifying Evan Lemoine CPA LLC.  If the payment date above falls on a weekend or holiday, I understand the charge may be made the following business day.

ACCOUNT TYPE Text Checking AccountSavings Account

ACCOUNT HOLDER

ROUTING #

ACCOUNT #  

BILLING ADDRESS