Credit Card Transaction

Information we need to process a credit card payment for you:
Claim Number:
Name of Cardholder:
Address:
City:
State:
Zip:
Dollar amount you are paying:
$
Phone Number:
and/or Fax Number:
Charge Card Type:
Charge Card Account Number:
Exp. Date :
/ (mm / yy)
3 or 4 Digit Code
(on the back of the card - last 3 or 4 numbers to the right)
E-mail Address:
You will be paying Williams, Alexander & Associates (WAA) and this name may appear on your banking statement.
 
   


 

 


This is an attempt to collect a debt, and any information obtained will be used for that purpose. Unless you notify this office within 30 days after receiving this notice that you dispute the validity of this debt or any portion thereof, this office will assume this debt is valid. If you notify this office in writing within 30 days from receiving this notice, this office will obtain verification of the debt or obtain a copy of a judgment and mail you a copy of such judgment or verification. If you request this office in writing within 30 days after receiving this notice, this office will provide you with the name and address of the original creditor, if different from the current creditor.

   
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