Automated Payments (ACH)Customer Authorization
                                                                                                                             Loan #                           
Save time & money by signing up for our new Automatic Payment Plan. For your convenience, and with the help of your bank, we can now automatically deduct your monthly payment from your checking account. No more checks to write! No more stamps to lick. Simply complete the information below and attach a voided check.  Return this information to:

Val-Chris Investments, Inc.
2601 Main Street, Suite 400
Irvine, CA 92614
                                                                     
Name
	
Address
	City
	State
	Zip Code
	
Phone Number
	E-Mail Address

Banking Information

Name of Primary Bank
	Name of Account
	
Bank Representative
	Bank Phone Number
	
Bank Routing Number (see example below)
	Bank Account Number (see example below)

PLEASE ATTACH A VOIDED CHECK TO THIS FORM

I hereby authorize a monthly ACH electronic debit from the account designated above to be paid to Val-Chris Investments, Inc., in payment for services rendered to me, not to exceed the amount agreed to by me below. I understand that a $5.00 transaction fee will be added for this convenient service.

I further understand that should my bank dishonor my automated payment for insufficient or uncollected funds, the original amount, plus an additional transaction in the amount of the state allowed NSF check fee may be electronically debited from my account.

I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law.

Signature
	Date

Agreed Upon Amount and Terms

My account will be debited on the ______________ day of each month starting _________/__________/_________.      

Monthly Payment Amount $                            Total amount to be drafted from my account $                       + $5.00.