authorization for direct payment - lively

Direct Payment Form Credit Card Payment Form

LIVELY INC. | ATTN: FINANCIAL SERVICES | P.O. BOX 4428 | CARLSBAD, CA 92018

In order to ensure appropriate processing,please include a voided check and mail completed form to: LIVELY INC. | ATTN: FINANCIAL SERVICES

P.O. BOX 4428 | CARLSBAD, CA 92018

Mail your completed form to:

ACCOUNT NAME:

PHONE NUMBER:

ADDRESS:

CITY: STATE: ZIP:

EMAIL ADDRESS (if available):

FINANCIAL INSTITUTION/BANK NAME: (please print):

ACCOUNT NUMBER AT FINANCIAL INSTITUTION:

FINANCIAL INSTITUTION ROUTING/TRANSIT NUMBER:

FINANCIAL INSTITUTION CITY AND STATE:

I acknowledge that the origination of Direct Payment (ACH transactions) from my account must comply with the provisions of U.S. law. This authoritywill remain in e�ect until I have cancelled it in writing.

SIGNATURE: DATE:

GDT-2976 CC / ACH WEB FORM JAN2022 V3

Financial Institution/Bank name

Account NumberRouting/Transit NumberB C

A

A

B

C

Payment OptionsTwo smart, easy and safe ways to make your payments: Direct payment or credit card.Choose your option and fill out the appropriate form below:

Which card would you like to use?

Visa Mastercard DiscoverAmex

CHOOSE ONE:

MONTHLY RECURRING ONE-TIME ONLY

ACCOUNT NAME:

LIVELY ACCOUNT NUMBER:

CARD NUMBER:

EXPIRATION DATE:

AMOUNT AUTHORIZED:

BILLING ADDRESS:

CITY: STATE: ZIP:

SIGNATURE:

DATE: