Geneva Capital AutoPay

If you wish to use the PDF form, you can fill it out, attach a copy of a voided check, and submit it via email (customerservice@gogc.com) or fax (320-762-8402).

Company Name

Agreement #

I (we) hereby authorize Geneva Capital LLC, Owner, to initiate, on the date my (our) payment is due, debit entries & to initiate, if necessary, credit entries & adjustments for any debit in error to my (our) account indicated below & the bank named below.

Bank Name

Account Type

Checking Savings

Routing # (9 digit, lower left of check)

Account #

Image of Voided Check (Please choose a valid JPEG or PNG of less than 5MB in size)

The authority is to remain in full force and effect until Owner has received written notification from me (us) of its termination in such time and in such manner as to afford Owner and the bank a reasonable opportunity to act on it. We understand that our withdrawal of this authority without the express written consent of Owner shall constitute a default of the Agreement for which this authorization is being made.

You understand that by providing an electronic signature below and clicking the "I Agree / Submit" button immediately following this notice, you agree that we may treat electronic record or a paper copy of the output received from electronic transmission as an original of this written Agreement.

Full Name