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nation-wide collection services

Check Payment

Please complete all items below. This form is secure and the information will be submitted securely.

RMA File #:

Date: MM/DD/YYYY
Amount:
Payment Type:

Please enter information as it appears on your check:

Payer:
Co-Payer:
Address:
City, State & Zip:
E-Mail Address:
Phone:

Bank Information:

Bank Name:
Bank Address:
City, State & ZIP

Bank Routing and Account Information

check routing numbers

Routing Number:

Account Number:

Check Number:
Check # Position:
Your e-mail address will only be used to send you a confirmation message that your check has been processed.  This information is not used for any other purpose.

   





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