Credit Card Authorization Form- Probatio

Credit Card Authorization

Please complete the form accurately and completely

First Name

Last Name

Card Holder Name

Day of Month Payments are Due

Card Number

3 digit code

Expiration Date

Billing zip code

I authorize Mid Missouri Community & Legal Services to charge my card for the agreed upon amount, and any past due fees or charges. I understand that my card information will be saved on file for future transactions. ARB (automatic reoccuring billing). I also understand that the credit company charges a four (4%) FEE for use of the card

I understand that if my due date lands on a weekend or a holiday, my card will be ran the prior business day

I agree at no time will I stop payment or authorization for use of this card by Mid Mo. I also understand my card will be charged an additional $5 for every month I am past due and/or a $30 rescheduling fee may be applied

Monthly Probation Fee; $40.00

Square Credit Card Fee: $1.61

Total Monthly Charge: $41.61

Sign and Date

Thanks for submitting!

Credit Card Authorization

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