Consumer Credit Counseling Service of Greater San Antonio(2)

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					                   Consumer Credit Counseling Service of Greater San Antonio

                                       Payment-By-Phone Authorization

During my (our) participation in the Debt Management Plan (DMP), I (we) want the option of making monthly
payments over-the-phone. I (we) give Consumer Credit Counseling Service of Greater San Antonio (CCCS)
and my Financial Institution the authorization to debit my personal bank account for the amount of my monthly
deposit or other amount which I (we) indicate.

I (we) will be charged a one time $1.00 activation fee and $1.00 every time I (we) make a payment over the
phone. I (we) will be assessed a $ 10.00 NSF fee for all returned debits to my account. This charge will be
added to my (our) monthly processing fee and deducted from my next DMP payment. In the event that my (our)
debit entries are returned NSF on three separate occasions, my privilege to use these new payment options may
be terminated.

I (we) understand that I must send in a payment, or call CCCS to submit a DMP payment over-the-phone every
month. My (our) authorization will remain active with CCCS until I (we) have cancelled it in writing.


(Financial Institution Name)


(Address)                                                 (City, State)                  (Zip Code)

__________________________________________ __________________________________________
(Routing Number)                        (Account Number)
                                                                                           For savings accounts,
Checking or Savings        *** Please attach your voided check to this form.***         please attach a letter from
(Circle One)                                                                                 your bank on their
                                                                                        letterhead confirming your
                                                                                        routing & account number
                                                                                           as well as all account
                                                                                               holder names.




_________________________________________                            _____________________________
(Account Holder’s Name Printed)                                       (Client Account Number)

_________________________________________                            _______________________
(Account Holder’s Signature)                                         (Date)

__________________________________________
(Joint Account Holder’s Name Printed)

__________________________________________                           ________________________
(Joint Account Holder’s Signature)                                   (Date)

                                                  Updated 03/17/11