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Account Information

Diaz & Associates File Number

Memo

Payment Information

First name

Last name

Card number

Expiration date

Security code

Address 1

Address 2

City

State

Country

Zip

Zip plus 4

Email address

Phone number

Payment ($)

You are agreeing to pay $ plus a Fee of $ (%) for a Total of $.

Number of Payments: 0

Confirmation

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I authorize Diaz and Associates to process the above payment of $. I also authorize Diaz and Associates to store this information in compliance with payment processing regulations and to charge the card listed above for future payments in accordance with their terms. I understand that to make any changes to this authorization I must contact Diaz and Associates prior to the payment date.

I authorize Diaz and Associates to process the payments as outlined in the payment schedule. I also authorize Diaz and Associates to store this information in compliance with payment processing regulations and to charge the card above for future payments in accordance with their terms. I understand that to make any changes to this authorization I must contact Diaz and Associates prior to the payment date.

Thank you for your payment. If you need further assistance please contact us at
1-877-544-2728.

THIS IS AN ATTEMPT TO COLLECT A DEBT BY A DEBT COLLECTOR AND ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE.

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