THE PURPOSE OF THIS COMMUNICATION IS TO COLLECT A DEBT.

Please fill out the form below. All fields are required. By submitting this form, I authorize Michael Harrison Attorney at Law to initiate an electronic funds transfer for the payment described here from the bank account I designate, or a credit card payment from the card number I submit.
Payment Summary:
Payment Date: 04/26/25
Payment Amount:
Account Number:  
Client IP: 3.141.29.234 
Credit/Debit Card Information:   
Card Type:

Name as on Card:
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Card Billing Zipcode:
Card Number:
Card Expiration Date: MMYY
Card ID (CVV2/CID/CVC) Number:
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Billing Information (if different than above):
Same as above
(must fill out city, state):
First Name:
Last Name:
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