Payment Form

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Payment Information

*Payment Type
Credit Card Electronic Funds Transfers

*Customer name

*Address

*City

*State (use "other" for out of USA)

*Zip

*Customer phone number

*The Bilateral Account Number

Client / Customer number

Copy info from the customer info above

*Name on the credit card

*billing address

*City

*State (use "other" for out of USA)

*Zip

*Credit card number

*Credit card type

*Expiration Date

*Security number

*Amount to apply to the account

*Name of Creditor (for debtors only)

A free text remarks field

*Verification Code

*Customer name

*Address

*City

*State (use "other" for out of USA)

*Zip

*Customer phone number

*The Bilateral Account Number

Client / Customer number

Copy info from the customer info above

*Name on the bank account

*bank account mailing address

*City

*State (use "other" for out of USA)

*Zip

*Account Type
Savings Checking
*Account Type
Personal Account Business Account
*Bank Account Number

*ABA (Routing) Number

*Name of the Bank

Location of bank branch

*Phone number of Bank

*Amount to apply to the account (i.e. amount of payment)

Name of Creditor (for debtors only)

A free text remarks field

*Verification Code

Credit Card Payments and Electronic Funds Transfer (EFT or Electronic Check) do not have a processing fee.
Bilateral Credit is a debt collector, and this is an attempt to collect a debt, and any information obtained will be used for that purpose.