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Payment Summary

Payment Date: 03/23/23
Payment Amount: $ *
Attorney: *
Matter ID:
Invoice # *

Checking Information

Account Holder Name: *
Bank Routing Number: *
Bank Account Number: *

Client Information

Client/Company Name *
Phone Number
Email Address *

I authorize Kimball, Tirey, & St. John LLP to charge my bank account indicated in this web form, for noted amount on today's date.


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