ACH Agreement

First Name *

Last Name *

Phone *

Email *

Name of financial institution: *

Address of financial institution: *

Routing Number: *

Checking/Savings Account Number: *

Account Type: *

Set amount to be withdrawn: *

Date for funds to be withdrawn: *

Signature *

Clear

I hereby authorize Paragon Home Plans to initiate a one-time debit to my checking/saving account at the financial institution listed below for the stated amount.