Please fill out the following information and press Submit at the bottom of the page.
Note: A convenience fee of $3 for each payment 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 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


Card Information


*Name On Card

*Type of card Mastercard Visa Amex

*Card Number

*Zip Code For the billing address

*Expiration Date  

*Payment amount		   *Date to make transaction  
$   mm/dd/yyyy  


Multiple Payments



If you wish to make arrangements for future payments on your account at this time, simply fillout 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   Date to make transaction  
$   mm/dd/yyyy  

3rd payment amount		   Date to make transaction  
$   mm/dd/yyyy  

4th payment amount		   Date to make transaction  
$   mm/dd/yyyy  

5th payment amount		   Date to make transaction  
$   mm/dd/yyyy  
 
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 credit card 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 for each payment. 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.