Complete this form to make your payment by electronic withdrawal from your checking account.
Please provide the following information:
First Name Last Name Middle Initial Work Phone Home Phone E-mail
Bank Routing (ABA) # - (first 9 numbers starting from the lower left corner of your check):
Account # - (please include any leading zeros - but do NOT include the Check #):
Check Amount - (enter the amount, in dollars and cents, that you are paying)