I/we authorize Novadebt (A Garden State Consumer Credit Counseling Organization) to initiate entries to my checking account indicated above and, if necessary, to initiate adjustments for any transactions credited in error. The authorization is to remain in full force and effect until Novadebt is notified by me/us in writing, via certified mail and/or return receipt requested, 30 days prior to the scheduled draft date or as long as it takes to afford Novadebt or the bank a reasonable opportunity to act on it, whichever is longer. No other form of cancellation will be effective or observed.

If a debit is returned unpaid due to “Uncollected”, “Insufficient Funds”, “Refer to Maker”, “Stop Payment”, “Closed Account”, etc. , Novadebt will not process it again, therefore, a payment must be submitted via another approved method. A $10.00 (ten) fee will be assessed for returned drafts.

I/we agree with all of the provisions of this authorization and hold Novadebt, its directors, employees, officers, and its agents harmless from any damages that may occur arising out of my/our authorization.

Signature ___________________________________                   (Applicant)                                  (Date)

Signature___________________________________                   (Co-Applicant)                                  (Date)

225 Willowbrook Road Freehold, New Jersey 07728 MG-DPL 04/19/01 Revised 10/15/03	Member AICCCA	800-77-BILLS fax 732-431-5248 www.novadebt.org