Before proceeding with this form, please make sure to provide us with a copy of the received letter, including all pages, front and back. Note that for us to respond, a Power of Attorney or Form 8821 may be required, and additional fees may apply.

I, hereby authorize this firms EA PA to charge the balance due as stated below for the services mentioned above. As the authorized cardholder or Corporate Officer, by signing below, I acknowledge and accept the terms outlined in this agreement. I agree to make payment and specifically authorize This Firms EA PA to charge my credit card for the services rendered. Furthermore, I agree that if my credit card becomes invalid, I will promptly provide a new valid credit card upon request to settle any outstanding balances owed.