Adler Wallach & Associates

AWA Collections

Payment Processing Portal

Personal Info

Payment Info

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Customer Account # *

First Name *

Middle Name

Last Name *

Address *

enter manually

Country *

Street 1 *

Street 2

City *

State *

Zip Code *

Phone Number

E-Mail Address *

you will be emailed a receipt of this transaction if address supplied

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WE ACCEPT FOLLOWING CREDIT CARDS

Name on Card *

Card Number *

Expire Date *

Security Code *

Payment Amount *

Name on Account *

Routing Number

Account Number *

Type *

Checking

Savings

Payment Amount *

I agree to the terms and conditions set forth in my Cardholder Agreement.*

I authorize the merchant listed above to electronically debit my account in the amount specified here on the following business day. I agree to provide the merchant with my Bank and Account information and hereby authorize the merchant to debit the Account in order to pay the designated payment. By authorizing a payment to be made through Easy Payment Now you are requesting an electronic transfer from your bank account. *

Please note that if you wish to revoke or discuss this authorization please call us at 1-800-111-1111 during business hours.

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Payment Amount:
Fee:
Total amount:
Sale ID:
Date & Time:
Status:

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This is an attempt to collect a debt and any information obtained will be used for that purpose. If you have any questions please contact us at 714-771-3690.