EFTA00300162.pdf

CaringPeople Credit Card Authorization Form • \N Client Name TERJE ROD LARSON ( Name on Card 0 Amex 0 Visa 0 Mastercard 0 Discover Card Number Exp Date Address City State Zip I authorize Caring People Homecare to automatically charge this credit card and subsequently any credit card given verbally/telephonically for all services rendered. Signature Date 0 Caring People Homecare creates invoices based on signed aide activity sheets or electronically verified visit at least every two weeks, at which time the authorized actions above will be charged for services rendered. A copy of the invoices and receipt of charges will be mailed accordingly. Please refer any questions or issues to the below contact information. A default of payment is considered when a client has any outstanding balance over 90 days from dale of invoice for services rendered. Caring People will make every effort to contact you in advance of any charges processed. Electric funds transfer debits and/or credits from the account identified above for payments due or when applicable, apply electronic funds transfer credits to the same. Furthermore, if any such electronic debil(s) should be returned by my financial institution as unpaid (Non-Sufficient or Uncollected Funds). I authorize. Caring People Homecare to collect a returned item fee of 925.00 (or the maximum amount allowed by state law) per item by electronic debit from the same account identified above. For accounting purposes, all electronic debits will be reflected on the monthly bank statement that corresponds with the financial institute identified above. This authorization is to remain in full force and effect until MERCHANT has received written notification of its termination in such time and in such manner as to afford MERCHANT reasonable opportunity to act on it or until the authorization expires. My such notice should be send to the address below. Clients paying by credit card will be charged an additional tee of 3% of the total bill. Fax this completed form to (718) 425-4603 Caring People Homecare Finance Group 118-35 Queens Blvd. Grd Floor Fore ' 3 9 Phon [marl EFTA00300162