GILMAN & EDWARDS
Secure Payment Form
Payment Summary
Payment Date
Payment Amount
Customer IP
Debit Card Information
Name as on Card
Card Billing Address
Card Billing Zip
Card Number
Card Expiration Date
CVV2/CID
Client Information
First Name
Last Name
Address
Address 2
City
State
Zip
Phone Number
Email Address
I understand and acknowledge that Gilman & Edwards, LLC, is considered a debt relief agency under applicable Bankruptcy laws and therefore unable to accept credit and/or charge card payments for certain services to be rendered. Accordingly, I agree to use only a Debit or Check card, and attest that the means of payment remitted herein is via a Debit or Check card.
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