Be sure this is the same address as your credit card.

We will send you a copy of your payment confirmation here.

Your payment will process every 30 days after this start date.

Your card will show "WSJM INC 2699251111" on your credit card statement.

By signing, I authorize Mid-West Family - South Bend to automatically deduct payment from my credit card to pay for my agreed contract with the company on a monthly basis. The authorization is to remain in effect through the term indicated on the form above. I understand that I am responsible for paying any additional invoices for services rendered outside of this invoice number or product contract not covered by this payment. If I need to make an adjustment to this schedule, I understand that I must contact the business manager within 5 business days of the next recurring payment date, that this current recurring schedule will be cancelled, and a new form will be filled out by my organization to begin a new schedule or payment amount.