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E-Check Rental Payment

* Today's Date

* First Name

* Last Name

* Street Address

Apt. #

Address Line 2

* City

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* Zip Code

* Phone Number

* Email Address

E-Check Information

* Checking or Savings? Checking Savings

* Name of Institution

Street Address

City

State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington DC

Zip Code

* Phone Number

* Rent Payment

* Routing Number

* Account Number

* Would you like to have your rent auto-drafted each month for free?

Yes. Please send the authorization form to my home so that I can get started next month!!

No, thank you.

* I give Houses, Inc. permission to withdrawl funds via ACH from my account.

Yes

No

* Indicates Response Required

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