Web Payment by Check

PAY BY CHECK AUTHORIZATION

To ensure payment gets applied properly, please provide the following information:
Did you receive a letter from us?*

YesNo
See link above payment form to find out how to locate your Debtor ID # and / or Original Creditor
Debtor ID/Ref #*
Original Creditor
Name on Account You are Paying*

First NameLast Name
Type of Checking Account*

PersonalBusiness
Name exactly as listed on check*
Amount you are paying*
Check # (optional)
Bank Name*
Bank City, State*
Bank Routing #*
9 - Digit Routing Number
Bank Account #*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*

Area CodePhone Number
Email Address*
example@example.com
EFT Authorization
By placing my digital signature below, I authorize the merchant to convert my check to an electronic funds transfer or paper draft, and to debit my account for the amount of the transaction. In the event that my draft or EFT is unpaid, I agree that a fee of $35.00 or as allowed by law may be charged to my account via draft or EFT.
Digital Signature
Please type your name to confirm that you have read the above statement and that you authorize McKenzie Paul and Associates to process the EFT as described above.
Should be Empty:

PAY BY CHECK AUTHORIZATION