Payment Auto Pay Confirmation

Payment Auto Pay Confirmation

Recitals

WHEREAS, Client Name: (hereafter "Client") is receiving services from Service Provider: (hereafter "Provider");

WHEREAS, Client and Provider have agreed that payments for services described herein will be made by automatic electronic debit or charge pursuant to the authorization below; and

WHEREAS, this Payment Auto Pay Confirmation memorializes the scope of services, payment terms, and the authorization for recurring automatic payments.

Scope of Work

Payment Terms

Payment Amount: $   Frequency:

Billing Day or Trigger:   Next Scheduled Payment:

Late Fee: If a payment is returned, declined, or not received by Provider when due, Client agrees to pay a late fee of . Provider may also assess a returned-item processing fee of .

Payment Method & Authorization

I authorize Provider to initiate electronic debits to the payment instrument designated below for the amounts and frequency set forth above. This authorization remains in effect until cancelled in accordance with the Term and Termination section.

Bank Account (ACH)    Debit/Credit Card

Term and Termination

Effective Date:   End Date (if any):

Either party may terminate this authorization and the underlying payment agreement by providing written notice to the other party at least days prior to the next scheduled payment. Termination does not relieve Client of obligations for amounts accrued prior to termination.

Client acknowledges that Provider may suspend or terminate services for failure to maintain valid payment credentials or for returned payments, subject to any cure periods required by the underlying service agreement.

Confidentiality

Each party shall maintain in confidence all account, payment, and proprietary information disclosed in connection with this authorization and shall not disclose such information except to its employees, agents, or service providers who have a need to know and who are bound by confidentiality obligations no less protective than those herein. Confidential information does not include information that is or becomes publicly available through no wrongful act of the receiving party or that is required to be disclosed by law, provided the disclosing party is given prompt notice when lawful and practicable.

Representations and Warranties

Client represents and warrants that it is authorized to provide the payment instrument information supplied, that all information provided is accurate and complete, and that sufficient funds or credit is or will be available on the scheduled debit dates. Client shall notify Provider promptly of any change in account or card information.

Governing Law

This Payment Auto Pay Confirmation shall be governed by and construed in accordance with the laws of the State of , without regard to its conflict of law rules.

Entire Agreement

This document, together with any underlying service agreement expressly incorporated herein, constitutes the entire agreement between Client and Provider with respect to automatic payment authorization and supersedes all prior or contemporaneous communications, representations, or agreements, whether oral or written, regarding the subject matter hereof. Any amendment must be in writing and signed by both parties.

Acknowledgment and Authorization

By signing below, Client authorizes Provider to initiate debit or charge entries to the account or card provided for the amounts and on the schedule set forth above. Client understands that this authorization will remain in effect until it is revoked in writing in accordance with the Term and Termination section. Client agrees that Provider may rely on this authorization and will not be liable for any claim arising solely from Client's failure to maintain sufficient funds or to timely update payment information.

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