Third Party Payment Authorization Form

THIRD PARTY PAYMENT AUTHORIZATION FORM

In 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 1

Address Line 2

City

State

Zip Code

Type 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 purposes

Expiration Date: *

Security Code: (CVV) *

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

Cardholder Name: *

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.

Today's Date: *

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