Secure Payment Form

Invoice Payment Information:
Invoice Amount:
Invoice Number(s):

Checking Account Information: Or, click to pay by credit card.


Name on Bank Account:
Bank Routing Number:
Bank Account Number:
By submitting payment information, you are authorizing American Financial Management, Inc. ("AFM") to reproduce this item as an 'ACH Transaction' for deposit on the date you submit the transaction. An ACH transaction will be produced utilizing the information from this form. A transaction that is returned for any reason may be subject to a returned item fee by your banking institution and will be subject to a $25.00 return item fee by AFM's banking institution. If a transaction is returned, AFM's banking institution automatically redeposits the returned transaction. Therefore, if the original transaction is dishonored or returned for any reason, you also authorize a second, subsequent attempt to clear this transaction. If the transaction is returned for any reason on the second deposit attempt, AFM's banking institution charges an additional $25.00 return item fee and disposes of the check. Thus, you agree to be responsible for the total transaction amount plus a returned item fee of up-to $50.00. By clicking on the "Process Payment" button you are accepting these terms and conditions and the stated fees for using this service.

Billing Information:
Company Name:
First Name:
Last Name:
Address:
Address Line 2:
City:
State:
Zip:
Country:
Phone Number:
Email Address: