Payment Summary:
Payment Date: 09/19/24
Payment Amount *:
HCS Reference/Account Number *:  
Description:  
           
Credit Card Information:
Card Type:

Name as on Card *:
Card Billing Address *:
Card Billing Zipcode *:
Card Number *:
Card Expiration Date *: MMYY
Card ID (CVV2/CID) Number *:
[What is the Card ID?]
   
Billing Information:
First Name:
Last Name:
Address:
Address Line 2:
City:
State:
Zip:
Phone Number:
Email Address:

THIS IS AN ATTEMPT TO COLLECT A DEBT AND ALL INFORMATION
OBTAINED WILL BE USED FOR THAT PURPOSE