Recurring Direct Payment Authorization Form

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To complete the changes to account form, simply fill out the information and hit submit. You will then receive a printable version to sign and date, then mail or fax in to complete changes to your account. Address and fax number are at the bottom of the printout under signature and date.

Corporate Headquaters

1384 Ingleside Road
Norfolk, Virginia 23502


Primary: 1-757-852-3300
Toll-Free: 1-800-242-9760
Peninsula: (757) 595-2808
North Carolina: (252) 491-5729


Request Type (Select One):

New
Change
Cancel

I, the customer identified above (hereinafter referred to as "Customer" or as "I" or "my", authorize Johns Brothers Security to initiate scheduled recurring electronic fund transfers from my checking account identified herein for payments due from time to time on the Johns Brothers Security Account Number shown above.

I understand that the scheduled payment dates will be the first business day of each month. I understand that authorization of electronic funds transfers from my checking account as the method of making payments on the account identified above, is entirely optional and is not required to obtain or maintain my account.

I understand that I may at any time, with written notice, request that electronic transfers from my checking account pursuant to this authorization be discontinued, and that Johns Brothers Security will not initiate further electronic transfers from my checking account pursuant to this authorization after Johns Brothers Security has received my written notice and had a reasonable period of time to act upon it.

I understand if an "item" is returned as insufficient funds, a returned debit item fee of $25.00 will be charged to my account. If a payment is returned two (2) months in a row, this account will be automatically cancelled from the Direct Payment Program.

I understand and authorize all of the above as evidenced by my signature below and acknowledge having read this authorization.