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Credit Card Authorization Form
This is the PDF for Credit Card Authorization - complete and have a copy sent to your email. You can then print, sign and send back via picture, scan, or in person.
Date - Authorization is completed *
MM
/
DD
/
YYYY
Time - Authorization is completed *
Your answer
Choose Option 1 - I authorize Independence Again to charge the unpaid balance in full as of date of authorization.
Choose Option 2 - I authorize Independence Again to charge an amount of:
Your answer
Choose Option 3 - I authorize Independence Again to charge the recurring payment of $150 each week
Choose Option 3 - for $150: Date Range for recurring payment (MM/DD/YYYY to MM/DD/YYYY)
Your answer
Choose Option 4 - I authorize Independence Again to charge the recurring payment of $2 each week
Choose Option 4 - for $2: Date Range for recurring payment (MM/DD/YYYY to MM/DD/YYYY)
Your answer
Credit card number: *
Your answer
Expiration Date *
MM
/
DD
/
YYYY
Security Code *
Your answer
Name On Card *
Your answer
Zip Code of Mailing Address *
Your answer
Name of Resident (First - Middle - Last) *
Your answer
Name of Supportive Family/Peer (First - Middle - Last) *
Your answer
Date of Authorization for Charges *
MM
/
DD
/
YYYY
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