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Client Payment Authorization Form

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

CHARGE POLICY:

ONE/FIRST TIME PAYMENT:

I hereby authorize Kevin Puckett Attorney at Law, LLC to charge the balance currently due for the amount of $.

POLICIES:

Payment made for services delivered by this firm is non-refundable.


Being the authorized account holder or the Corporate Officer, by signing above I understand and agree to the terms set forth in this agreement, agree to pay, and specifically authorize to charge my account for the 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.

CARDHOLDER INFORMATION:

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

The undersigned guarantees performance of the financial provisions of this agreement.

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