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Account Information

Account Number

Memo

Payment Information

First name

Last name

Card number

Expiration date

Card 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 $.

Confirmation

Are you human?

By checking the box to the left, you are indicating that you give Alternative Recovery Management authorization to process the above payment of $.

By checking the box to the left, you are indicating that you give Alternative Recovery Management your authorization to process the payments as outlined in the payment schedule above using the payment method listed above. To revoke your authorization you must contact Alternative Recovery Management.

This communication is from a debt collector. This is an attempt to collect a debt. Any information obtained will be used for that purpose. For further information regarding your account please call Alternative Recovery Management at 1-800-525-2433. Thank you for your payment.

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