eCheck Payment

Items marked with () are required.

Your Information
Account:   (as it appears on the collection notice)
First Name:   (Name as it appears on the Collection Notice)
Last Name:   (Name as it appears on the Collection Notice)
Address:  
City/State/Zip:  
Phone:  

Banking Information
  Payor
Account Holder's First Name:  
Account Holder's Last Name:  
Address:   Check if the same as above:
City/State/Zip:  
Phone:  
Email:  
 
  [Where to Find ]
 
 

Transaction Information
Amount:  
Please: No dollar signs or commas. Only digits and a single decimal point (e.g., 50.00)


This transaction does not constitute a payment arrangement.
This is an attempt to collect a debt. Any information obtained will be used for that purpose.
By checking this box, I certify, under penalty of law, that the information provided is correct -and- that I accept the terms of this agreement as presented in the contract.