[dba]
Customer Name:
Invoice #:
Payment Amount:
$
Payment Amount cannot be more than Invoice Amount
Invoice Amount:
$
1
2
3
1.
Payment Method
Card
ACH
Next
→
2.
Payment Details
First Name
Last Name
Account Type
Checking
Savings
Routing Number
Account Number
Confirm Account Number
Account Holder's Name
Email Receipt to
Card Number
Expiration Date
CVV
Name on Card
Billing Street Address
Postal Code
Email Receipt to
Convenience Fee:
$
Total Amount:
$
0.00
Convenience Fee
$
Total Amount:
$
0.00
Total Amount:
$
0.00
Send
Pay Now
→
I authorize
[dba]
to initiate a one-time ACH/electronic debit[s] to my account ending in
in the amount of
$
. I agree that ACH transactions I authorize comply with all applicable law.
By clicking on
“Pay Now”
, I hereby authorize
[dba]
to initiate an electronic single debit entry from the above indicated bank account in the amount entered (or provided) on this page. I understand that if this transaction is submitted after 6:00 PM Eastern Standard Time, it will have an effective date of no sooner than the next business-banking day and will show as a withdrawal from my account on that date. If I wish to revoke this authorization, and revoke this payment, or the amount withdrawn from my account is different than the amount authorized herein, I may call
[csn]
during
[dba]
business hours which can be found by visiting their website:
[website]
. Furthermore, I assert that I am the owner or an authorized signer of the bank account provided.
By clicking Pay Now, I agree to pay
[dba]
the above amount in accordance with the Card Issuer Agreement. I acknowledge the added Credit Card Convenience Fee of
.
By clicking Pay Now, I agree to pay
[dba]
the above amount in accordance with the Card Issuer Agreement. I acknowledge the added Credit Card Convenience Fee of
.
By clicking Pay Now, I agree to pay
[dba]
the above amount in accordance with the Card Issuer Agreement.
3.
Payment Confirmation
[accountName]
, [GratitudeText]
Customer
Invoice #
Deposit Amount
$
Convenience Fee
$
Payment Amount
$
Card Number
xxxxxxxxx1234
Card Type
Card Number
Card Type
Visit Our Website
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