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.