State! 2 : Request for State Farm Payment Plan's Recurring Monthly Payment Option: 1326-0812-19 | hereby authorize State Farm®affiaes and subsidiaries (State Farm) and the financial institute designated (or any other fancal inettuton | may authorize al any time) to deduct/charge monthly regular recurring payments required forthe payment of insurance or Joan repayments from my chosen method below from either my financial account or credildebit card ‘This authoily remains in effect until State Farm has received writen or electronic notification from me of its termination atleast ten (10) ‘business days before the next scheduled payment at the appropriate address provided below. Financial Institution name: BANK OF AMERICA, NA. Financial Institution routing/ransit number: 063000047 Financial Institution account number: ..6547) ‘Account type: CHECKING Last 4 characters on card number: NIA Expication: WA, [tis my responsibilty to provide and maintain the most up to date and accurate financial information shown above. Hf any transaction isnot honored by my financial institution, the policies or oans wil be considered not paid. State Farm wil ask me to pay the dishonored transaction amount witha replacement payment and will suspend the recurring payment option. Aer timely Feplacement payment i received by State Farm, recuting payment option wil resume. Stato Farm has the right to charge me for any payment dishonored by my financial institution or any payment that i received after the due dat. ‘State Farm has the right to discontinue the recurting payment option for any reason. State Farm will send notification to me atleast fen (10) days in advance whenever the payment amount or the requested payment date changes. | understand and agree State Farm has no obligation to and wil not apply any loan repayment amount toward any payment which is unpaid. State Farm may revise the terms of his agreement a anytime upon written notification. | acknowledge that | have received and agree to the terms of the Stale Farm Payment Plan Agreement Note ~ the date of the actual deductionicharge may vary based onthe processing times ofthe financial institutions, es RSS Taare are . lores R_pSils ow BM aw 9242015, Fate PE saat Date Contact Information: [MANNY MIRANOA 16806 5 OXXE HWY PALMETTO BAY, FL 33157-4368 (eossi-8413 [MANNY MIRANDA CUNS@STATEFARM.COM ‘State Farm Affliate Insurers: ‘The ype of payment pan and the statin wich the insured ves wil determine which ol he State Farm afiates wil iis the authorized ecuring edublonicharge, An insured may have an agreement wih more than one Stale Fam aia for erent premium payment plans and dierent payment options. ‘The Stale Farm afte insurers are: ‘State Farm Mutual Aulomobile Insurance Company ‘State Farm Fre and Casualty Company ‘State Fam Intemational Ul Insurance Company, LTD ‘State Farm General Insurance Company ‘Slate Farm Life and Accident Assurance Company Slate Farm Fda Insurance Company State Farm Lie Insurance Company State Farm Loyés Sate Farm Guaranty Insurance Company State Far Indemnty Company Slate Farm County Mutual insurance Company of Texas 125329 Pritedin USA. 11-22-2019, sonse04 2002 14164 202@StateFarm RECEIPT OF PAYMENT FOR SFPP ACCOUNT 1326-0812-19 ACCOUNTHOLDER(S) WILSON, DELORES A 5120 ROYAL PALM BEACH BLVD WEST PALM BCH FL 33411-9071 AGENT MANNY MIRANDA. 16896 S DIXIE HWY PALMETTO BAY, FL 33157-4366 (805)251-8413 PAYMENT DATE PAYMENT TYPE CHECK #/ REF # AMOUNT 09-24-2015 ELECTRONIC FUNDS TRANSFER 1T2GEBA1 $147.73 TOTAL AMOUNT PAID: $147.73 iene ‘AUTHORIZED SIGNATURE: ALICIA ARGUELLO ‘THANK YOU FOR YOUR PAYMENT. PAYMENTS ARE RECEIVED SUBJECT TO COLLECTION AND POLICY PROVISIONS. WE APPRECIATE YOUR BUSINESS. 2924185308180000101015111110131010. 1" 2 13, State Farm® Payment Plan Agreement By payment of the inal premium and set up fee to establish this State Farm Payment Plan (SFPP) account, you agree to the terms of this SFPP account, as set forth below. If at any time you de not agree to any of these terms, notify your State Farm agent who will help you determine the payment method available and you will be billed directly using that payment method for each insurance policy. Subject to the provisions below, this agreement is intended to continue for as long as you are a State Farm insured, ‘This SFPP agreement is between you and the State Farm Mutual Automobile Insurance Company. its subsidiaries of affiliate insurers (State Farm) for the payment of premium on the insurance polices issued to you by the various affliated State Farm insurance companies. This SFPP agreement is NOT an insurance application. This SFPP ‘agreement alters only your obligation to pay premium in advance forthe full erm of the various State Farm policies. Except for item 8 below, the other terms of those insurance polices are not altered by this SFPP agreement. State Farm agrees to accept periodic premium payments (monthly, quarterly, semiannually) rather than the full premium for the entire term of your insurance policies. In order to continue coverage, you must pay the full amount of the periodic premium payment and premium installment charges. The premium installment charge applies as listed below: + Non Recurring Accounts $3.00 + Recurring Accounts Print Bling Notice $2.00 (Requested a bling be mailed each month) + Recurring Accounts $1.00 ‘Automated Recurring Accounts are only available for eligible monthly biling modes. f you change the type of ‘periodic premium payments on the SFP, it does not alter terms of this agreement. ‘You may pay premium for more than one State Farm policy through your SFPP account. In that case, each periodic payment through your SFPP account is the premium installment charge and the total of the periodic premium payment due for each of the State Farm policies paid for through your SFPP account. We wil not credit the periodic payment received to any one specific policy unless you clearly indicate otherwise with, or prior to making, the periodic payment. Wat any time within a single year you receive three (3) cancellation notices for failure to pay, you may be ineligible to continue your SFPP account. The discontinuation of an SFPP account does not relieve you of the obligation to pay premiums due on your State Farm insurance policies. ‘You may close your SFPP account at any time by merely providing notice to State Farm or your State Farm agent. Closing your SFPP account does not relieve you of the obligation to pay premiums due on your State Farm insurance policies, Separate bilings may be sent to you for each insurance policy. ‘You oF State Farm may cancel a State Farm policy in accordance withthe terms and conditions of that State Farm policy. if you wish to cancel any or all policies on your SFPP account, you must comply with the procedures ‘ultined in each of those policies. It any of your State Farm policies paid through this account result in paid unearned premium, State Farm may: ‘a. Credit any money due to you against the premium owed by you on any other State Farm insurance policy paid for by you through your SFPP account; or 'b. Refund the money to you. ‘State Farm has the right to close your SFPP account at anytime. ‘The set up fee, premium installment charge and earned periodic premium payment paid by you are not refundable, If you signed and completed the Request for State Farm Payment Plan's Recurring Monthly Payment Option, ‘authorizing the deduction of your premium payments from your financial account, you also agree to the terms of this SEPP Agreement as set forth above. This SFPP agreement does not in any way affect the terms of the Request for State Farm Payment Plan's Recurring Monthly Payment Option. ‘State Farm may revise this SFPP agreement at any time upon written notification STATE FARM INSURANCE COMPANIES ‘35m Poreain USA. 02272011,