LaviCPA

Payment Authorization Form

Complete and submit this form to authorize LaviCPA to process a tax payment on your behalf from your checking account on file. A confirmation copy will be emailed to you immediately upon submission.

AUTHORIZATION NOTICE: By submitting this form, you authorize LaviCPA and its designated agents to initiate a one-time electronic funds transfer (ACH debit) from the checking account on file with our office, as identified by the last four digits you provide below. This authorization is valid for the single payment amount and date specified herein. You have the right to revoke this authorization by contacting our office at 323-463-2600 prior to the scheduled payment date. LaviCPA will not share your banking information with any third party except as required to process the authorized payment.

Section 1Client Information

Full Legal Name *

Email Address *

Phone Number

Section 2Payment Details

Payment Type *

Amount Authorized ($) *

Requested Payment Date *

Section 3Account Verification

To verify your identity and confirm the account on file with our office, please provide the last four digits of your checking account number and your bank name. We do not collect or store full account numbers through this form.

Bank / Financial Institution *

Last 4 Digits of Checking Account *

Section 4Authorization & Signature

I, the undersigned, hereby authorize LaviCPA (7707 Sunset Blvd, Los Angeles, CA 90046) to initiate a single electronic funds transfer (ACH debit) from my checking account ending in ****XXXX held at [Bank Name] in the amount of $1,000.00 on or around [Date] for the following purpose: [Payment Type].

I understand that this authorization is for a one-time payment only. I confirm that I am an authorized signer on this account and that the account has sufficient funds to cover the authorized amount. I acknowledge that I may revoke this authorization only by contacting LaviCPA at 323-463-2600 prior to the scheduled payment date. This authorization constitutes my electronic signature and is legally binding.

Electronic Signature — Type Your Full Name *

By typing your name above, you are signing this authorization electronically. This electronic signature has the same legal effect as a handwritten signature.

I have read and understand the authorization above. I confirm that all information provided is accurate and that I am authorized to initiate this payment from the account identified. I authorize LaviCPA to proceed with the transaction as described. *

Authorization Date:September 3, 2026

* All required fields must be completed and the authorization checkbox must be checked before submitting.

A confirmation copy will be sent to your email address. LaviCPA | 7707 Sunset Blvd, Los Angeles, CA 90046 | 323-463-2600