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Autopay By Bank Account (ACH)
Please fill out the following to pay by bank account (ACH).
Or call (800) 205-4683 to speak with a representative.
Account Holder Name:
I give permission to Hyper Protect to charge my bank account for the following charges.
One Time (Single Transaction)
Recurring on the
Week
Month
quarter
Year
This payment is for the following:
Billing Information
Billing Address
City/State/Zip
Telephone
email
Banking (ACH) Information
Checking
Savings
Name of Account
Bank Name
Routing #
Account #
You authorize a single (1) or regularly scheduled charge to your bank account. You will be charged the amount indicated below each billing period. A receipt for each payment will be provided to you and the charge will appear on your bank statement. You agree that no prior notification will be provided unless the date or amount changes, in which case you will receive notice from us at least ten (10) days prior to the payment being collected.
Customer Name
Date
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