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Card Number *

Security Code

Exp. Month

Exp. Year

Name On Check *

Account Number *

Routing Number *

Check Number

Type of Account*

Check Type*

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(all fields required unless noted)

First Name *

M.I. (optional)

Last Name *

Address 1 *

Address 2 (optional)

City *

State

Zip Code *

Phone (for billing-related questions) *

Disclosures

I authorize STEPHEN NIERMANN PLLC to process the above payment. I also authorize STEPHEN NIERMANN PLLC to store this information in compliance with payment processing regulations and to charge the bank account listed above for future payments in accordance with their terms. I understand that to make any changes to this authorization I must contact STEPHEN NIERMANN PLLC prior to the payment date. If you have any questions, problems, or need to change or cancel your payment, or if you need your current balance, call Customer Service at 800-800-9579.

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