Multiple Payments Authorization Form

THIS FORM IS NOT TO BE USED BY MASSACHUSETTS DEPARTMENT OF REVENUE ACCOUNTS

This is an attempt to collect a debt and any information obtained will be used for that purpose.

Who do you owe the money to?

Account/Reference Number

I authorize The Allen Daniel Associates, Inc. to deduct from my (select only one)  Debit card Credit card, per the following instructions:

Payment Frequency (select only one):  Weekly Biweekly Monthly

Payment Amount: $

Payment Start Date:

 FOR “CONSUMERS” ONLY. I am not providing The Allen Daniel Associates, Inc. with an e-mail address provided to me by my employer or related in any manner to my workplace or place of employment. I am acknowledging that I do not have a reasonable expectation of privacy in an e-mail address associated in any way with my employment. I am also acknowledging that I am aware of who else in my household may intercept Electronic Communications (for example, family members and roommates) and have taken all precautions to eliminate others from accessing my Electronic Communications.

Email:

Address:

Telephone Number:

Is this a cellular phone?  Yes No

Do we have your consent to call your cell phone?  Yes No

Electronic Signature

After sending this email authorization form, please call 800-882-2100 and select option 1 to securely provide your debit/credit card information if you have not already done so.

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