[su_row][su_column size=”1/3″]File Num: [73] Payment Amount: [74] Debtor Name: [75] Special Instructions: [76] Name: [79] Last: [105] Address: [81] City: [82] State: [83] Zip: [84][/su_column] [su_column size=”1/3″]Credit Card Type: [87] Name on Credit Card: [88] Credit Card Number: [89] Credit Card Number: Expiration Month: [90] Expiration Year: [91] CVV: [92] CVV: Confirmation Recurring: [93] When Recurring: [94][/su_column] [su_column size=”1/3″]Amount of Recurring: [95] Other: [96] Special Instructions: [97] Phone: [100] Cell: [101] Email: [102][/su_column][/su_row]
[su_row][su_column size=”1/3″]File Num: [73] Payment Amount: [74] Debtor Name: [75] Special Instructions: [76] Name: [79] Last: [105] Address: [81] City: [82] State: [83] Zip: [84][/su_column] [su_column size=”1/3″]Credit Card Type: [87] Name on Credit Card: [88] Credit Card Number: [89] Credit Card Number: Expiration Month: [90] Expiration Year: [91] CVV: [92] CVV: Confirmation Recurring: [93] When Recurring: [94][/su_column] [su_column size=”1/3″]Amount of Recurring: [95] Other: [96] Special Instructions: [97] Phone: [100] Cell: [101] Email: [102][/su_column][/su_row]