Electronic Debit Processing Information

I, , hereby authorize LifeTrek, Inc. of 121 Will Scarlet Lane, Williamsburg, VA 23185-5043 to initiate an ACH debit entry to the following checking or savings account in the amount shown below for monthly coaching services. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law and that by my submission of the data contained herein I agree to be bound by said law.

The specific debit to my checking or savings account authorized herein may only post on or after the posting day in the billing cycle listed below, and in no event may the debit transaction post to my account prior to the posting day.

I understand that this payment agreement will be in full force and effect until services have been completed or are ended by request of the client either verbally or in writing at the address listed above.

Note: To authorize an electronic debit, you will need to provide your checking or savings Account number and financial institution Routing number. Do not provide your Debit card number.

The financial institution Routing number can be found on the Microline at the bottom of a check or deposit slip. It is always 9 digits long, begins with 01–12 or 21–32, and appears between the characters. It is usually (but not always) the first set of numbers on the check or deposit slip, as in the numbers highlighted in red on the following example:

The Account number for a checking or savings account can also be found on the Microline at the bottom of a check or deposit slip. It does not include the check or deposit slip number, can never be more than 17 characters long, usually appears before the character, and may (but does not always) have a dash between the numbers, as in the numbers highlighted in red on the following example: .

When typing the numbers below, do not type the dash or any punctuation.

AUTHORIZATION to ACH  

Depository Name:
Routing Number:
Account Number:
Effective Date:
Posting Day:
Amount:
Customer Name:
Customer Address:
LifeTrek Billing Cycle:
Coach's Name:
Authorized Signature:  

 

Customer Phone:
Customer E-Mail:
Today's Date:


Complete this form on-line except for the signature, print it out, sign it manually, and return it to LifeTrek, Inc., 121 Will Scarlet Lane, Williamsburg, VA 23185-5043 by Fax (772-382-3258) or Surface Mail.