This authority is to remain in full force and effect until the Association has received written notification from me (or either of us) of its termination in such manner as to afford Blue Life Texas, LLC a reasonable opportunity to act on it.

ALL APPLICANTS MUST PROVIDE A COPY OF THEIR DRIVER’S LICENSE AND A VOIDED CHECK OR DEPOSIT SLIP WITH THIS APPLICATION. If this form is received after the 10th of the month then the ACH Debit will not be drawn from your account until the following month. If the ACH Debit is declined due to Insufficient Funds or other similar circumstances our return check fee of $30.00 will apply.