I hereby certify, as payor of this bill, I have funds available in my account on the specified transaction date. I also understand if my payment is returned for any reason, I will be liable for the $35.00 fee that will be charged.
(30 character limit)
See upper left hand corner of your invoice
Please provide street address and city (60 character limit)
$
(0000.00 no commas and max is 5000)

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