Client Payment Authorization Form

CLIENT PAYMENT AUTHORIZATION FORM

(last hereby Name:

In an effort to simplify your billing experience, our law office offers online payments for your convenience.

CHARGE POLICY:

I hereby agree to the following: *

✓ I, being the authorized account holder or the corporate officer, understand by signing below I agree to the terms set forth in this agreement, agree to pay, and specifically authorize to charge my account for the legal services provided. I further agree that in the event my account information becomes invalid, I will provide new valid information upon request, to be charged for the payment of any outstanding balances owed with Kevin Puckett Attorney at Law, LLC. - $2,000.00
✓ I understand that payment(s) made for legal services delivered by this law office is non-refundable. - $2,000.00
✓ I hereby authorize Kevin Puckett Attorney at Law, LLC to charge my debit and/or credit card the balance currently due in the following amount: - $2,000.00

*Please check all of the above boxes if you understand and agree.

Total Dollar Amount I Hereby Authorize Kevin Puckett Attorney at Law, LLC to Charge My Debit and/or Credit Card: *

*Entire the full dollar amount above you are authorizing Kevin Puckett Attorney at Law to charge your account (credit or debit card).

CARDHOLDER INFORMATION:

Cardholder's Legal Name: *

First

Middle

Last

Cardholder's Billing Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Type of Card: (Click One) *

Card Number: (last 4 digits of card only) *

*Per PCI Compliance guidelines, the last 4 digits may be recorder for verification purposes.

Card Expiration Date: *

Card Security Code: (CVV) *

The undersigned guarantees performance of the financial provisions of this agreement. I hereby authorize Kevin Puckett Attorney at Law, LLC to charge my debit and/or credit card the balance currently due above

Today's Date: *

SIGNATURE OF CARDHOLDER (PLEASE READ EVERYTHING CAREFULLY & THEN SIGN BELOW TO AGREE): *

Clear Signature

✓ Note: You must CLEARLY sign your FULL name above. If your signature is not legible, your will be asked to re-fill/re-submit this entire form. This law office does not undertake to represent you until a separate and written agreement for representation (called a Retainer Agreement) has been executed by you and the attorney.

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