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Consumer Authorization for Direct Payment Via ACH

Direct Payment via ACH is the transfer of funds from a consumer account for the purpose of making a payment.

Check one: Begin PaymentChange Information

I (we) authorize Footprints Design LLC dba DakotaQ Internet Services to electronically debit my (our) account and, if necessary, to electronically credit my (our) account to correct erroneous debits as follows:

Select one: Checking AccountSavings Account

at the depository Financial Institution named below. I (we) agree that ACH transactions I (we) authorize comply with all applicable laws.

Financial Institution Name:

Routing Number:

Account Number:

Name(s) on Account:

Debit Transaction Frequency (Typically recurring):

Single Entry (one-time payment)

Recurring Entries (entries that recur at substantially regular intervals, without further affirmative action by the Receiver)

Date of debit (usually by the 15th of each month):

Number of and/or frequency of debits (monthly):

Authorized debit amount (or method for determining amount such as an invoice):

I (we) understand that this authorization will remain in full force and effect until I (we) notify COMPANY in writing by email to sales@dakotaq.com that I (we) wish to revoke this authorization. I (we) understand that COMPANY requires at least 30 days prior notice in order to cancel this authorization.

September 18, 2024

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Your legal name

Your email address

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Timestamp

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June 20, 2024 3:25 pm MDT

Consumer Authorization for Direct Payment Via ACH Uploaded by - IP 24.111.1.54