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)

Modal dialog

You wont be able to dismiss this by usual means (escape or click button), but you can close it programatically based on user choices or actions.