Dexter Financial Services - Authorization for Automatic Payment

I authorize Creditor and the bank named below to initiate variable entries to my checking/savings account. This authority will remain in effect until I notify Creditor or the bank in writing to cancel it in such time as to afford the bank a reasonable opportunity to act on it. I can stop payment of any entry by notifying Creditor or my bank ten days before my account is charged. Should I choose to revoke the Automatic Payment Plan, I agree to a 1% increase in my monthly payment amount. I can have the amount of an erroneous charge immediately credited to my account up to 15 days following issuance of my bank statement or 46 days after posting, whichever occurs first.

DFS Account Number:

Name on Checking Account:

Company Address:

Authorized Signature and Title:

Date:

Bank Name:

City:

State:

Email:

Checking Account Number:

Bank Routing Number:

(located between the symbols :000000000: on the bottom of your check)

Please attach a voided check.

FOR OFFICE USE ONLY SUPPLEMENT/CONTRACT #	DUE DATE	AMOUNT (NOT INCLUDING TAX)