Account Number:



First Name:

Last Name:

Address:


City:

State:

Zip:

Email for receipt:

Amount (format 0.00):


Bank Account Type:

Bank Routing Number:

Bank Account Number:

Usio, Inc. processes ACH transactions on behalf of National Management Recovery. By clicking ‘Submit’ below you agree to pay via this ACH Authorization. You acknowledge that you are voluntarily choosing to pay electronically. You understand and acknowledge that you may terminate the ACH Authorization by notifying us at support@usio.com, subject: ACH Authorization Disputes, and in such time and manner as to afford us and your bank a reasonable opportunity to act on it.




  

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