Auto-Debit Recurring Billing Authorization Form
_______________________________________ Bauer & Bauer, LLC
City _______________________________________ 939 Keystone Way
State ________________________ Zip __________ Carmel, IN 46032
Email _______________________________________ 317-581-9353
Please select only one payment option below:
___ *Bank Account Information ___ Credit Card Information
___ Checking ___ Savings ___ MasterCard ___ VISA ___ American Express ___ Discover
Bank Name Name on Credit Card
Bank Routing Number Credit Card Number
____________________________ ____________________ **Customer address is same as credit
Bank Account Number Expiration Date (mm/yy) card billing address ___Yes ___No
*Automatic Withdrawal from Checking or Savings
Important: Please enclose a copy of a voided check for checking account debits or a voided deposit slip for savings account debits.
**If the address is not the same, please provide credit card billing address: ________________________
Number of Months in Recurring Billing = _____________
Transaction Date in Month = _____________
Total Monthly Payment Amount = _____________
I hereby authorize Bauer & Bauer, LLC (Bauer) to perform scheduled charges/debits from the indicated credit card/bank
account. I agree that this is a periodic charge that will be made according to my billing preference, and that to terminate
the recurring billing process I must either cancel my account, or arrange for an alternative method of payment. I
understand that all account cancellations must be made in writing according to the requirements of the Bauer Terms of
Professional Services Agreement, which I have read and understand. I will not dispute Bauer’s recurring billing with my
credit card issuer so long as the amount in question was for service rendered prior to my canceling my account in
manner required by the Terms of Professional Service Agreement.
For ACH debits to my checking/savings account, I understand that because this is an electronic transaction, these
funds may be withdrawn from my account as soon as the above noted transaction date. I acknowledge that the
origination of ACH transactions to my account must comply with the provisions of U.S. law.
I agree that if I have any problems or questions regarding my Bauer service, I will contact Bauer for assistance, using
the contact information located on their website at www.hudaudits.com. I agree that I will not dispute any charges from
Bauer unless I have already attempted to rectify the situation directly with Bauer and those attempts have failed.
I authorize Bauer and their payment gateway to run an address verification search. This verification process is a
security measure to protect me, the client, from illegal fraud against my credit card. I guarantee and warrant that I am
the legal cardholder for this credit card, and that I am legally authorized to enter into this recurring billing agreement
BY SIGNING AND DATING BELOW, I CONSENT TO THE TERMS OF THE AUTHORIZATION
AGREEMENT FOR ACH DEBITS AND CREDIT CARD CHARGES ABOVE.
Authorized Signature Date
email, or mail this form to the following: firstname.lastname@example.org; 939 Keystone Way, Carmel, IN 46032