Authorization Form for Direct Payment

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Please correct the field(s) marked in red below:

  • The direct payment program is a free program to pay through your checking or savings account.
  • Your ACH payment will be debited from your account on the 15th of the month (if the 15th is on Saturday, Sunday, or a holiday, then it will be debited from your account the Friday prior to the 15th).
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Applicant Information
 *
Applicant Information
2
Select one of the following:
 *
Select one of the following:
3
Bank Information
 *
Bank Information
4
Account type:
 *
Account type:
5

Terms and Conditions Agreement

Click here to view terms and conditions

 *
6
Typed Name
7
Today's Date
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