Name on Bank Account *

First Name

Last Name

Accountholder Signature (type your name as your signature) *

By typing my name and hitting the submit button, I am authorizing The Mercer law Office d/b/a Mercer Kutch to initiate a monthly ACH/electronic debit in the amount indicated from the bank account I have designated above. The debit is to occur in accordance with the above schedule, and I understand that the authorization will remain in full force and effect until the transaction is cancelled by me by contacting Mercer Kutch. Any request for cancellation shall afford Mercer Kutch a reasonable opportunity to act on such request. I certify that (1) I am authorized to debit the bank account above and (2) that the ACH/electronic payment I am authorizing complies with all applicable laws. By clicking on the Submit Button, you agree to pay the above amount in accordance with the above schedule and agree to provide your information to help process your payment.

First Name

Last Name