Automatic Payment Application

Hate to write checks?  We understand. So here's a great way to save checks, time and postage! Enroll in our Automatic Payment Plan, and your monthly Sievers billing amount 
will be deducted from your checking account on the due date automatically. You'll never miss a payment, even when you're out of town. 

  To apply, please fill out the required information below and then press the "Submit" button.

Note:  Please submit this form at least 15 days prior to payment to allow sufficient time 

          for processing.

Customer Information

All fields must be completed

Sievers Account Number

 your account number is on your statement in the upper section under the Statement Date

Name

 as shown on your statement

Daytime Phone

Checking Account Information

Name

 as shown on checking account

 

use the example above to fill in the following fields with the numbers from the bottom of one of your checks

Routing Number

   (9 digits)

Account Number

Financial Institution

Financial Institution

Address

City & State

Phone Number

Debit Amount and Authorization

IMPORTANT: Please fill in the monthly debit amount below 
before clicking the "Submit button

By clicking the "Submit" button, I (we) authorize the Financial Institution 
named above to pay and charge my account equal monthly payments of

 

(enter in 99.99 format)

payable to and drawn by Sievers Company for use in payment of my monitoring service.  I agree that each payment shall be the same as if it were an instrument personally signed by me.  

 

This authorization is to remain in effect until revoked by me in writing.  In addition, I have the right to stop payment of a charge by timely notification to my financial institution prior to charging my account.  I understand that both Sievers Company and the financial institution named reserve the right to terminate this payment plan or my participation therein.

 

Click the SUBMIT button to send your Automatic Payment application, or RESET to start over:

                                                                                 

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