Authorization for Recurring Payments – Credit Card – Autopay

I (we) hereby authorize Golden Star Properties, LLC to charge the listed credit card/debit card on a monthly basis as specified below for my (our) portable building lease payments. (NOTE: Fields with a * are required.)

Credit Card Account Number*

Enter Bank Address, City, State, and Zip Code

Name on Card*

Enter the name/phone number of your bank contact

Expiration Month*

Month your Credit Card Expires

Expiration Year*

Year your Credit Card Expires

Zip Code of Billing Address for Card*

Enter the zip code on your credit card account

Select Payment Day*

Select the day (1st through 12th) for your monthly payment

Amount to Withdraw Each Month*

Enter the monthly payment you wish to make

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.

Your Name*

Enter Your Name

Your Email Address*

Enter Your Email Address

Your Golden Star Properties Account #*

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

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

Any Special Instructions

Please enter any notes or special instructions

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