1666 Garnet Avenue. Suite 140 San Diego, CA 92109 Phone. 619.615.2023 Fax. 619.615.2056

KWIK PAYsm DEBIT FORM

PLEASE DEBIT MY: CHECKING ACCOUNT SAVINGS ACCOUNT

Customer Name(s) ________________________ ID Number (SS#) __________________

Beginning Debit Date ______/______/______ and thereafter on the ______ of each month

Please place voided check here

PLEASE PRINT ALL THE NUMBERS THAT APPEAR ACROSS THE BOTTOM OF YOUR CHECK : CHECK NUMBER AS IT APPEARS ON THE VOIDED CHECK ABOVE

Name of Bank	________________________________________________________
Bank Address	________________________________________________________
Phone #	________________________________________________________

Client Signature (s) _____________________________________ Date ______________

Please note: Any changes or cancellations concerning the EFT must be submitted in writing to our office three business days prior to the existing debit date. If notice is not given within the specified period of time, your account may be debited.