Auto Debit Program

This page is NOT a secure form. Please call Customer Service and we will mail, fax, or email a blank form for you to return. 954-753-0380 option 1

To have your payments automatically debited from your checking account, fill out the form below. We also need a voided check, so after filling out the information below, please write VOID on the check and either mail it to our office, or fax it to (954) 753-8784.

Normally your payments will be drafted on the billing cycle following signup. To know when the debit process will start, look at the "Amount Due" box for the words "AUTO-DRAFT" or "Will be drafted on or before due date".

If you have any questions about our automatic debit program, please feel free to contact us online or by phone at (954) 753-0380.

Are you signing up for or cancelling auto-debit? *



First name: *
Last name: *
Service Address: *
Address 2:
City: Coral Springs
State: FL
Zip code: *
Contact phone number:*

Service account number: *

(9 digits, no dashes)

Please use a blank, voided check for the following information. You will need to mail or fax the check to our office so we can match it to your account. Please do not use a deposit slip as some banks use a different routing number for checks and deposit slips.

Bank name:*
Routing number * Account number * Check number *

(9 digits)