Credit Card Payment

Items marked with () are required.

Debtor 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:  

Credit Card Information Note: This address must match the address where the credit card statement is mailed. Providing incorrect information will cause the transaction to be declined, however, a temporary "Hold of Funds" may be placed on your credit card for a length determined by the card issuing bank (an average length of 7 days).

  Payor
Cardholder Name:   (as it appears on the card)
Address:   Check if the same as above:
City/State/Zip:  
Phone:  
Email:   (your receipt is sent to this address)
 
Card Type:  
Card Number:  
Expires:   - (mm-yyyy)
Card Verification (cvv2):  

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

Contract

You are about to request a payment be made electronically using your credit card. You must agree to the following.

  1. I authorize a charge to the above specified credit card.
  2. By completing and submitting this form, I affirm that:
    1. I have read, understand and agree to be bound to the terms of this agreement
    2. I am authorized to perform this transaction by the legal party to the debt(s)
    3. I am authorized to perform transactions using the card information provided


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.