+1 (816) 384-1640 Mon - Fri 9:00am - 5:00pm . . . Free Consultation Pay Invoice Home Attorney Profile Practice Areas Accolades & Awards Testimonials FAQ Contact Pay Invoice Free Consultation Call Home Attorney Profile Practice Areas Accolades & Awards Testimonials FAQ Contact Pay Invoice Free Consultation Call Home Attorney Profile Practice Areas Accolades & Awards Testimonials FAQ Contact Pay Invoice Third Party Payment Authorization Form Please enable JavaScript in your browser to complete this form.THIRD PARTY PAYMENT AUTHORIZATION FORMIn an effort to better serve our clients and simplify your billing experience, our law office offers online payments for your convenience.THIRD-PARTY PAYMENT: (Initial) I, , authorize Kevin Puckett Attorney at Law, LLC to charge the balance currently due for the amount of $. (Initial) By signing I, , understand I am paying for legal fees on behalf of, , a client with this law office. I understand I will receive no direct benefit from this transaction or the legal services provided. I also understand I am waiving my right to dispute this charge with my bank for claims of services not received or similar claims of non-service. CARDHOLDER INFORMATION:Cardholder Name: *Cardholder Billing Address: *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeType of Card: (choose one) *Card Number: (last 4 digits of card only) **Per PCI Compliance guidelines, the last 4 digits may be recorder for verification purposesExpiration Date: *Security Code: (CVV) *The undersigned guarantees performance of the financial provisions of this agreement.Cardholder Name: *Signature of Cardholder: * Clear Signature Today's Date: *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Captcha * = WebsiteSubmit78571