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Direct Payment Form Credit Card Payment Form
LIVELY INC. | ATTN: FINANCIAL SERVICES | P.O. BOX 4428 | CARLSBAD, CA 92018
In order to ensure appropriate processing,please include a voided check and mail completed form to: LIVELY INC. | ATTN: FINANCIAL SERVICES
P.O. BOX 4428 | CARLSBAD, CA 92018
Mail your completed form to:
ACCOUNT NAME:
PHONE NUMBER:
ADDRESS:
CITY: STATE: ZIP:
EMAIL ADDRESS (if available):
FINANCIAL INSTITUTION/BANK NAME: (please print):
ACCOUNT NUMBER AT FINANCIAL INSTITUTION:
FINANCIAL INSTITUTION ROUTING/TRANSIT NUMBER:
FINANCIAL INSTITUTION CITY AND STATE:
I acknowledge that the origination of Direct Payment (ACH transactions) from my account must comply with the provisions of U.S. law. This authoritywill remain in e�ect until I have cancelled it in writing.
SIGNATURE: DATE:
GDT-2976 CC / ACH WEB FORM JAN2022 V3
Financial Institution/Bank name
Account NumberRouting/Transit NumberB C
A
A
B
C
Payment OptionsTwo smart, easy and safe ways to make your payments: Direct payment or credit card.Choose your option and fill out the appropriate form below:
Which card would you like to use?
Visa Mastercard DiscoverAmex
CHOOSE ONE:
MONTHLY RECURRING ONE-TIME ONLY
ACCOUNT NAME:
LIVELY ACCOUNT NUMBER:
CARD NUMBER:
EXPIRATION DATE:
AMOUNT AUTHORIZED:
BILLING ADDRESS:
CITY: STATE: ZIP:
SIGNATURE:
DATE: