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Electronic Post Date And Payment Authorization

The following form will allow you to authorize Diversified Credit Systems to automatically debit your checking account or charge your credit card based on the payment arrangements you have made with our office on your balance due.

DCS#		Re-Enter DCS#
RequiredInvalid format.Exceeded maximum number of characters.Minimum number of characters not met.		RequiredThe values don't match.
Responsible Party		Phone Number (optional) Enter Numbers Only
Required		Invalid format.
Address		Email Address
Required		RequiredInvalid format.
City State (Example: TX) Zip Code   Required RequiredMinimum number of characters not met.Exceeded maximum number of characters. RequiredInvalid format.
Please enter the last four digits of either the bank account or credit card that you are using for payment arrangements.
Last Four Digits	Re-Enter Last Four	Enter Payment Amount
RequiredInvalid format.	RequiredThe values don't match.	RequiredInvalid format.
Choose Payment Frequency Below		Comments or Special Instructions
One Time Payment Draft Weekly Draft Monthly
Name of Person Authorizing Payment (Electronic Signature)
You Must Agree To The Terms To Continue IMPORTANT!!! READ - I have checked all information above and confirm that all information is correct. I agree that by clicking submit I am authorizing Diversified Credit Systems to draft my checking account or credit card as agreed upon in my payment arrangement. I may contact Diversified Credit Systems at anytime to stop future drafts or charges. However, I understand if I do that my payment arrangements will be null and void and my bill will due in full immediately.