www.jwylaw.com
jwylaw@jwylaw.com
ACH PAYMENT AUTHORIZATION
Company Name: Jenkins & Young, P.C. for the benefit of the creditor on the account number
below
I (we) hereby authorize Jenkins & Young, P.C., hereinafter called COMPANY, to initiate a one
time debit entry from my (our) Checking Savings account (select one). The account
information, as well as the depository name, hereinafter called DEPOSITORY, are indicated
below.
Depository (Bank) Name:
Transit/ABA (Routing) No.:
Checking/Savings Account No.:
First Name: Last Name:
Jenkins & Young, P.C. Account #:
Amount to debit:
By signing this form, you give us permission to debit your account for the amount
indicated on or after the indicated date. This is permission for a single transaction only,
and does not provide authorization for any additional unrelated debits or credits to your
account.
Signed: ___________ _________________________ Date: ________ _______________
*If you wish to revoke your authorization for this one-time ACH payment, you must contact our office 2
business days prior to the date you authorized the payment in this Authorization.
Pursuant to the Fair Debt Collections Practices Act, you are put on notice that we are
attempting to collect a debt and any information obtained will be used for that purpose. This
communication is from a debt collector.
P.O. BOX 420, LUBBOCK, TEXAS 79408-0420 ǀ Toll Free: 855-771-1235 ǀ Fax: 806-771-8755
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