Shield RTO Holdings LP d/b/a Shield Leasing

2820 S. Alma School Rd., Suite 18-450

Chandler, AZ 85286

customerservice@myshieldleasing.com

(480) 254-7890

Recurring Payment Authorization Form

Voluntarily schedule your rental purchase payments to be automatically deducted from your checking or savings account or charged to your credit or debit card. Just complete and sign this form to get started!

Recurring Payments Will Make Your Life Easier:

1. It's convenient (saving you time and postage)
2. Your payment is always on time (even if you're out of town), eliminating your risk of a default

Here’s How Recurring Payments Work:

You authorize regularly scheduled rental purchase charges to your checking or savings account or your credit or debit card. You will be charged the amount indicated below each billing period until the designated expiration date. A receipt will be emailed to you for each payment. You agree that no prior notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected.

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Please complete the information below:

I ________________________ authorize Shield RTO Holdings LP d/b/a Shield Leasing (“Shield”) to charge my bank account indicated in the table below for payment of scheduled payments under a Rental Purchase Agreement between me and Shield.

Billing	Phone
Billing Address ________________________	Phone# ________________________
City, State, Zip ________________________	Email ________________________

Billing	Phone	Saving
Account Type	Checking	Saving
Name on Acct	________________________
Bank Name	________________________
Account Number	________________________
Bank Routing #	________________________
Bank City/State	________________________

Authorization Expiration Date: ________________________

SIGNATURE ________________________ DATE ________________________

I understand that this authorization will remain in effect until the designated expiration date or until I cancel it in writing, whichever comes first, and I agree to notify Shield RTO Holdings LP d/b/a Shield Leasing (“Shield”) in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. I acknowledge that any changes I make to my account information via an online Customer Portal at www.myshieldleasing.com will be considered written notice of change and will constitute authorization to charge the new account in place of the account identified on this form. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. Charges to my checking or savings account may be processed, at Shield’s sole discretion, as an ACH transaction or debit. I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case a payment is rejected for Non-Sufficient Funds (NSF) or a closed account, I understand that Shield may at its discretion attempt to process the charge again within 30 days, and agree to an additional charge of up to $25.00 (or, if less, the maximum permitted under applicable law) for each attempt returned NSF or closed account which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH or debit transactions to my account must comply with the provisions of U.S. law.  I agree not to dispute these scheduled transactions with my bank provided the transactions correspond to the terms indicated in this authorization form.

Credit or Debit Card Backup Authorization Form

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.

credit
Credit or Debit Card Information
Credit Card / Debit Card :
Card Type : MasterCard / VISA / Discover / AMEX / Other : ________________________
Cardholder Name (as shown on card):________________________
Card Number: ________________________
Expiration Date(mm/yy): ________________________
Cardholder ZIP Code (from credit card billing address):________________________

To prevent a default under my Rental Purchase Agreement with Shield RTO Holdings LP d/b/a Shield Leasing (“Shield”), in the event that a payment under my Rental Purchase Agreement from my checking or savings account is rejected for Non-Sufficient Funds (NSF) or a closed account, I authorize Shield to charge my credit or debit card listed below. I understand that my information will be saved to file for future transactions on my account.

Customer Signature : ________________________ Date : ________________________