Mary Jane Elliott P.C. PRA IOLTA
Secure Payment Form
THIS FIRM IS A DEBT COLLECTOR. WE ARE ATTEMPTING TO COLLECT A DEBT AND ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE.
Payment Information:
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Payment Date:
07/16/25
Payment Amount:
*File Number:
Checking Account Information:
Account Holder Name:
Bank Routing Number:
Bank Account Number:
Debtor Information:
Company Name:
*First Name:
*Last Name:
Address:
Address Line 2:
City:
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Country:
Phone Number:
Email Address:
Terms of Collection
I understand that Mary Jane Elliott, P.C. is a law firm and a debt collector and that this is an attempt to collect a debt and any information obtained will be used for that purpose. I authorize Mary Jane Elliott, P.C. to debit the bank account indicated in this web form, for noted amount on today’s date. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted transaction date. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that the business may at its discretion attempt to process the charge again within 30 days, and I understand that there may be an additional charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I will not dispute merchant debiting my checking/savings account, so long as the amount corresponds to the terms indicated in this web form.