ACH Setup

Company Name(Required)

Contact Name(Required)

Payment Agreement

I authorize Lucca Alla Moda to initiate debit entries to my (our) Checking account indicated below and the depository institution listed above. I further authorize Lucca Alla Moda to initiate any correcting (credit) entry. I understand that the authorization may be rejected or discontinued by Lucca Alla Moda at any time. If any of the above information changes, I will promptly complete a new authorization agreement. This authority is to remain in full force and effect until Lucca Alla Moda has received written notification from me (us) of its termination.

Account Holder Type(Required)

Account Holder Name(Required)

Bank Name(Required)

Account Number(Required)

Routing Number(Required)

Hidden

Effective Billing Date

1st of the month

15th of the month

Hidden

Monthly Amount

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Payment Agreement