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?
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
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