Payment Transfer Authorization Form

Payment Transfer Authorization Form

Authorization to apply overpayments to outstanding balances

I understand and agree to apply any additional payments, overpayments, and credits within any organization managed by APCM to be applied to any balance I may have with any other company managed by APCM. By filling out, consenting to, and signing the below, I agree and authorize the movement of monies to and from the entities managed by APCM to satisfy all balances prior to being issued any refunds.

Last Name

First Name

Date of Birth

Electronic Signature

By typing my full name and checking the consent box below, I acknowledge and agree that my action constitutes my electronic signature, which has the same legal force and effect as a handwritten signature. I affirm that I have reviewed the information provided on this form and agree to its terms.

Type Full Name

Consent

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