Authorization for Recurring Direct Payments – E-Check – ACH – Autopay

I (we) hereby authorize Golden Star Properties, LLC to debit entries to my (our) account indicated below and the Financial Institution, to debit same such account. I (we) acknowledge the origination of ACH transactions to my (our) account must comply with the provisions of U.S. Law. (NOTE: Fields with a * are required.)

Name of Your Bank*

Enter the name of your Financial Institution

Bank Branch Name

Enter your Financial Institution's Branch Name

Bank Address*

Enter Bank Address, City, State, and Zip Code

Contact Person and Phone Number of Bank

Enter the name/phone number of your bank contact

Routing Number*

9 digit number at bottom left of your check

Account Number*

Your bank account number

Account Type*CheckingSavings

Select One Account Type

Select Payment Day*1st5th12th

Select the day for your monthly payment

This authority is to remain in full force and effect until your rental contract is complete or you provide Golden Star Properties with a written request to terminate automatic payments and you receive confirmation of termination at least 5 business days before a scheduled payment. In the event a check or an ACH Debit item is returned unpaid, a Returned Check fee will be deducted from your banking account in the amount of $30.00.

Your Golden Star Properties Account #*

Your Account Number (your cell phone or main phone number)

Amount to Withdraw Each Month*

Enter the monthly payment you wish to make

Your Name*

Enter Your Name

Name of Second Party on Your Account

Enter Name of Account Co-Owner If Applicable

Your Signature (Sign in Box Using Mouse or Keypad)*

Second Party's Signature (Sign in Box Using Mouse or Keypad)

Your Email Address*

Enter Your Email Address

Attach a Photo of Your Check*

You may attach a photo of a void or sample check

Any Special Instructions

Please enter any notes or special instructions

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