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Automatic Bank Withdrawl Form

This form will authorize Keel & Nassour, L.L.P. to begin an automatic draft to your bank account within five (5) business days of the date this authorization is signed.



I authorize Keel, Nassour and Heilman, L.L.P. to begin automatic draft of $20 per month to be processed for the month in which it was received from my bank account as indicated above. I understand that my enrollment in the legal defense plan is for a one year period and that payment will continue on a monthly basis unless I provide a 30 day written notification of cancellation. In the event there are insufficient funds when a draft is charged to my account, I agree to pay a $25.00 NSF fee. Anniversary date renewal will be automatic unless I provide said written notice of cancellation. I further agree to inform Keel, Nassour and Heilman, L.L.P. of any account changes that would affect the monthly withdrawal. The effective date of my coverage will begin on the date of the withdrawal; however, I understand that the coverage will be retroactive to the date the application is signed.

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Acknowledgement
By inputting your name above and checking this box, you acknowledge that you have read the above information.