|
Paying
by Check |
|
Please
Print and Fax or
Mail |
| Check#: |
_________________________________ |
| Name
of Bank: |
_________________________________ |
| Amount
of Check: |
$________________________________ |
| Creditor
You Are Paying: |
_________________________________ |
| Agency
Account Number: |
$________________________________ |
| 9
Digit Routing
Number: |
_________________________________ |
| Bank
Account Number: |
_________________________________ |
| Name
on Check: |
_________________________________ |
| Your
Name: |
_________________________________ |
| Phone/Fax#: |
_________________________________ |
| Address: |
_________________________________ |
| City: |
_________________________________ |
| State: |
|
| Zip: |
_________________________________ |
| |
|
