ACH Form | Rissa Crozier

Recurring Payment Authorization Form

Schedule your payment to be automatically deducted from your bank account, or charged to your Visa, MasterCard, American Express or Discover Card. Just complete and sign this form to get started!

Here’s How Recurring Payments Work:

You authorize regularly scheduled charges to your checking/savings account or credit card. We accept Visa, MasterCard, American Express and Discover card. You will be charged the amount indicated below each billing period. A sales receipt for each payment will be emailed to you and the charge will appear on your bank statement as an "ACH Debit". Your payment will be processed between the 1st and 3rd business day of the month, depending on weekends and bank holidays. You agree that no prior notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected.

Please complete the information below:

First Name

Last Name

Billing Address

City

State

Zip Code

Phone

Checking/Savings Info

What type of account?

Name on Account

Bank Name

Bank Account #

Bank Routing #

Bank City & State

Credit Card Info

What type of credit card is it?

Cardholder Name

Card Number

Exp Date

CVV Code

By submitting this form you are authorizing risboombah LLC to charge my credit card or bank account, as indicated below, on the 1st of each month of each billing period for payment for services in accordance with my Service Agreement.

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify risboombah LLC in writing of any changes in my account information or termination of this authorization at least 10 days prior to the next billing date. If the above noted payment date falls on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction date. In the case of an ACH transaction being rejected for Non-Sufficient Funds (NSF) I understand that risboombah LLC may at its discretion attempt to process the charge again within 1-2 days, and I agree to pay any bank service fees related to the NSF. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card / bank account and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated in this authorization form

I accept terms & conditions

Your Signature

Thank you! Your information has been submitted.