AUTHORIZATION FOR |
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AUTOMATIC PAYMENT OF MONTHLY FEES |
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| I hereby authorize _______________________ and/or Acri Commercial Realty, Inc., as Agent, to directly debit my checking/savings/charge account on or about the 6th day or each month at the financial institution indicated below for my monthly payment. Such direct debit will be made on each succeeding month, unless I choose to terminate this agreement in writing. Any such notification shall become effective following receipt, after a reasonable opportunity to act on it. | |
| _________________________________________________ | |
| Signature | |
| _________________________________________________ | |
| Print Name | |
| _________________________________________________ | |
| Address (Please indicate all units to be debited.) | |
| _________________________________________________ | |
| Phone Number | |
| _________________________________________________ | |
| Email Address | |
| Start Month:______________________________________________ | |
| (Completed form must be received in our office by the 1st day of the "start" month.) | |
| Please indicate method of payment: | |
| ____________Checking Account | (Please attach a voided check) |
| ____________Savings Account | (Please attach a voided check) |
| ____________Credit Card** | (Please complete the following information) |
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| **Credit Card holder will be charged a monthly service fee of 2.70% of the amount charged. | |
| New Payment Plan: ___________ | Change made to existing Payment Plan: ___________ (Check one) |
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| Remit all authorization forms to: | |
| Acri Commercial Realty Inc. | |
| 290 Perry Highway | |
| Pittsburgh, PA 15229 | |