AGICEN

One Time - Online eCheck Payment SSL

Items marked with an * are required.

Please view our privacy policy and view instructions before paying.

Customer Information
* Name: (first last)
* Address: Unit:
* City/State/Zip:
* Phone:
* Email: (your receipt is sent to this address)


Banking Information
Payor (must be the account holder) Same As Above
* Account Holder's Name:
* Address: Unit:
* City/State/Zip:
* Account Holder's Phone:
* Email: (your receipt is sent to this address)
* Account Type:
* Transit/ABA Number: Where to Find
* Re-Type Transit/ABA Number:
* Account Number:
* Re-Type Account Number:
* Institution Name:


Transaction Information
* Today's Date:// mm/dd/yyyy (All payments processed same day or next business day)
Memo:
* Amount: Please: No dollar signs or commas. Only digits and a single decimal point (e.g., 50.00)
Total Charge:
I accept the above 'Total Charge' that will be debited from my account.


Contract

You are about to request a payment be made electronically from your checking or saving account. You must agree to the following.

  1. Transactions are processed by Ascensions Group, Inc. through M & T Bank Treasury Management Automatic Clearing House (ACH)

  2. I authorize a debit entry to my account in the entity named above (financial institution)

  3. I authorize the financial institution to accept and to debit the amount of my entry to my account.

  4. Should this transaction fail for any reason (including invalid account numbers, closing my account before notifying AGI to stop debiting, insufficient funds, etc.) I understand that additional penalties, fees and interest may accrue.

  5. By completing and submitting this form, I affirm that:

    1. I have read, understand and agree to be bound to the terms of this agreement

    2. I am authorized to perform this transaction by the legal party to the debt(s)

    3. I am authorized to perform transactions using the banking information provided.

By checking this box, I certify, under penalty of law, that the information provided is correct and that I accept the terms of this agreement as presented in the contract



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