Authorization and Agreement Form Automatic

Authorization and Agreement Form
Automatic Credit Card Payment
Electronic Funds Transfer (EFT)
I authorize Balco Properties Ltd. LLC to process an Electronic Funds Transfer (EFT) / Automatic Credit Card Payment every month
to pay my monthly rent, and parking (if applicable). The transaction will occur on the ____ of the month. If this day is not a banking
day (‘banking days are weekdays other than bank holidays”), the transaction will be made the prior banking day.
Check which applies: (Complete the appropriate section below)
Electronic Funds Transfer (EFT-Attach a voided check)
Automatic Credit Card Payment
Lessee Name: _________________________________________________________
Leased Address:__________________________City:_____________State:____Zip:_______
Lease ID #:___________________________
Monthly Rent: $_________
Electronic Funds Transfer Information:
Print Name on Bank Account:____________________________________________
Bank Name:__________________________________________________________
Address of Bank:_________________________City:_____________State:_____Zip:_______
Automatic Credit Card Information:
Credit Card Type (Circle One): Visa
Exact Name on Credit Card:_____________________________________________
Credit Card Number:__________________________________Exp. Date:________ Card Verification Number:_____
Billing Address:__________________________City:_____________State:____Zip:_______
I understand and agree that:
• This automatic credit card payment or EFT authorization will remain in effect until Balco Properties Ltd. LLC has received
written notice at 1624 Franklin Street, Suite 1115 Oakland, CA 94612 to cease the automatic credit card or electronic funds
• The amount of the payments on my credit card or my bank account may be increased or decreased according to the rent
schedule in the lease agreement. However, no increase or decrease for any other reason will become effective unless I receive
at least 5 days advance notice of the change. The notice of change will be sent to my current address on file with Balco
Properties. I will notify Balco Properties of any changes in my address.
• If my credit card is declined or if there are insufficient funds in my bank account, or if my financial institution refuses to
honor a transfer request for any other reason, I will separately pay Balco Properties Ltd. LLC for the monthly rent I owe
under my lease agreement.
• It is my responsibility to separately pay Balco Properties Ltd. LLC for the monthly rent until the automatic credit card
payment or EFT process has been established with my bank. This set up may take up to one monthly billing cycle.
Automatic Credit Card Payment / Electronic Funds Transfer is for billing of monthly rent and parking (if applicable) only.
Printed Name
Authorized Signature
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