Employer Payment Authorization Provide authorization for a one-time payment and/or update reoccurring payment options. Step 1 of 3 0% Company Name*Group, Client Name or Sole Proprietorship Contact Name* First Middle Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Authorization*One-time payments can be used to replace a missed payment or any other balance owed. You may select both a one-time payment and reoccurring payments if applicable. One-time payment Reoccurring payments One-time payment amount*Reoccurring Payments*Planstin will process reoccuring payments for monthly amount due. Payments will be on the first of each month. I agree to allow Planstin to process monthly payments as enrolled. Additional Instructions Yes, I have additional instructions to provide. Additional InstructionsPlease include any additional instructions needed if not already provided. Account Type*IMPORTANT: Additional fees apply to card transactions. Checking Credit Card Card Number Expiration MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberExpiration Year20172018201920202021202220232024202520262027202820292030Security Code Cardholder Name Name of Bank Bank State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingName on Account* Routing Number* Account Number* Authorization* I authorize Planstin Inc and Planstin Administration Solutions to charge my bank account indicated above for my enrolled benefits. Returned payments are subject to a $25 returned payment fee. Processing Fee* I accept the processing fee of 3% of the one-time payment. Signature*Name* Δ
