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Account Information

Account number

Memo

Payment Information

First name

Last name

Card number

Expiration date

Security code

Address 1

Address 2

City

State

Zip

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 United Adjustment Service Inc to process the above payment of $. I also authorize United Adjustment Service Inc 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 United Adjustment Service Inc prior to the payment date.

I authorize United Adjustment Service Inc to process the payments as outlined in the payment schedule. I also authorize United Adjustment Service Inc 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 United Adjustment Service Inc prior to the payment date.

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