Third Party Payment Authorization Form

INFORMATION: CARDHOLDER (choose

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: *

Captcha *

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