Rash Curtis: Online Check Form

Please fill out the following information and press Submit at the bottom of the page.
Note: a convenience fee of $3 per check will be applied.
Confirmation of your transaction(s) and a printable record will appear immediately.
Receipts available upon request only after credit transaction clears.

Account Information

Collection account number		*indicates required field

*Name (s) on account		*Creditor name

*Your Phone Number		Your Email

Place of employment		*Work/daytime phone

Spouse's name	Place of employment	Work/daytime phone

*Home Address
	Street

*City	*State	*Zip

Check Information

*Name(s) as appears on check

*Address -

Check if same as above

Street

*City	*State	*Zip

*Name of bank	*City	*State

*Routing Number Need Help?	*Account Number

*Payment Amount		*Check number		*Date to make deposit
$				mm/dd/yyyy

	Multiple Payments (post-dated checks)
	If you wish to make arrangements for future payments on your account at this time, simply fill out the boxes below. It is our policy to mail a reminder letter 7-10 days prior to deposit. Please make sure funds are available to avoid a returned check fee of $25.

2nd payment amount	Check Number	Date to make transaction
$		mm/dd/yy
3rd payment amount	Check Number	Date to make transaction
$		mm/dd/yy
4th payment amount	Check Number	Date to make transaction
$		mm/dd/yy
5th payment amount	Check Number	Date to make transaction
$		mm/dd/yy


Yes	No

Please email me a reminder notice 7-10 days prior to transaction date.

By submitting this transaction request, I authorized Rash Curtis & Associates
to debit my bank account on the date(s) and in the amount(s) listed above. I understand this is a one time authorization that will cover only the transactions listed above plus a convenience fee of $3.00 per check. Contact info.

Please note: Online Payments submitted after 3:00pm Pacific time, will be
credited the following business day

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