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Automatic Payment Authorization Form Member/Group Name: ___PO Box 91110, Attn: Premium Billing Sioux Falls, SD 571091110 (888) 8454468 | TTY: 711 Fax: 6053286812 Email:DOB (if applicable): ___ Member

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How to fill out automatic payment authorization form

01

Obtain the automatic payment authorization form from your bank or financial institution.

02

Fill in your personal information such as name, address, and contact details.

03

Enter your bank account information including account number and routing number.

04

Specify the amount you authorize to be automatically deducted from your account and the frequency of payments.

05

Sign and date the form to authorize the automatic payments.

Who needs automatic payment authorization form?

01

Individuals who want to ensure timely payment of bills without the hassle of manual payments.

02

Businesses that want to streamline their payment processes and avoid late fees.

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What is automatic payment authorization form?

An automatic payment authorization form is a document that grants permission for recurring payments to be withdrawn from a person's bank account or charged to their credit card automatically.

Who is required to file automatic payment authorization form?

Anyone who wishes to set up automatic payments, such as individuals or businesses making regular payments for services, bills, or subscriptions, is required to file an automatic payment authorization form.

How to fill out automatic payment authorization form?

To fill out an automatic payment authorization form, you need to provide your personal information, account details, amount to be paid, frequency of payments, and signature to authorize the transaction.

What is the purpose of automatic payment authorization form?

The purpose of an automatic payment authorization form is to ensure that payments are made consistently and on time without the need for manual processing by the payer.

What information must be reported on automatic payment authorization form?

The information that must be reported includes the payer's name, contact information, payment amount, method of payment, payment schedule, and authorization signature.

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