Payment Processing Authorization

I (we) request a representative from Brumbaugh & Quandahl, P.C. L.L.O. to contact me by phone to establish an Electronic Funds Transfer (check 21) withdrawal of funds as ordered by me (us) from my (our) account, that we will provide over the phone.

 
Debtor Information *Bold fields are required
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Name:
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Authorization: By clicking on the Submit box, I (we) request a representative from Brumbaugh & Quandahl, P.C. L.L.O. to contact me by phone to establish an Electronic Funds Transfer (check 21) withdrawal of funds as ordered by me (us) from my (our) account, that we will provide over the phone. This authorization is to remain in full force and effect until I have fulfilled my obligation with Brumbaugh & Quandahl, P.C. L.L.O. OR Brumbaugh & Quandahl, P.C. L.L.O. has received written notification from me (us) of its termination in such time and in such manner as to afford Brumbaugh & Quandahl, P.C. L.L.O. and my bank a reasonable opportunity to act on it, or I also authorize you to debit or credit my (our) account if an adjustment is required. I authorize Brumbaugh & Quandahl, P.C. L.L.O. to verify my bank account information as needed. I (we) also authorize Brumbaugh & Quandahl, P.C. L.L.O. to contact me by phone, email, and or cell phone to discuss my debt.