Collection Agency - Chasemax, Inc.

Pay Bill Online

Name on Account	Check Number
Date:
Pay To The Order Of _Chasemax, Inc.___________________________ Dollars
Memo
Routing Number------------------ Account Number
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Creditor your paying
First Name
Last Name
Phone
Fax
Check Mailing Address
Check State and Zip Code

I am authorizing Chasemax, Inc. to debit my account for my payment. In an effort to not inconvenience me, if my payment is dis-honored or returned for any reason, I am authorizing the electronic debit of my account for the amount of the dis-honored payment plus the recovery fee allowed by the state and any applicable taxes. You may wish to print and and retain a copy of this authorization for your records.