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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:


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


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:

*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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