I authorize Community Justice Center to initiate, and my financial institution to honor, a one-time electronic debit from my account on the date, for the amount, and from the account listed.

I authorize Community Justice Center to store and initiate electronic payments from my indicated account, and authorize my financial institution to honor such payments. This authority is for the amount and dates listed, and is to remain in effect until canceled by Community Justice Center, my financial institution, or me. I can cancel my authorization for recurring payments by contacting Community Justice Center at . I also confirm that this constitutes my written authorization/signature to enroll in recurring payments, and to store my account information on file for future transactions.