Agency Payment Entry Form

Execution Reports

Forfeiture Payment

Large Bond Payment

Transfer bond Payment

Miscellaneous Payment

Overnight Shipping Fees Repayment

Total Amount Owed To Palmetto Surety

Payment Method

Payment Details

The above-mentioned Agent has agreed and accepted (via proxy) to be legally bound by the transaction terms below and the Palmetto Surety Refund Policy, and Privacy Policy

By submitting this form, you give Palmetto Surety Corporation or its Agent full permission to charge or debit your selected payment method for the above amount on or after the indicated date. This permission granted is for this single transaction only. I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I know that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above-noted regular transaction dates. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF), I understand that the merchant may, at its discretion, attempt to process the charge again within 30 days and agree to an additional $100.00 charge for each attempt to return NSF which will be initiated as a separate transaction from the authorized recurring payment. I also acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or credit card company so long as the transactions correspond to the terms indicated in this authorization form.