Quick Payment - Independence Capital Recovery

Account Information

Reference Number:

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First Name:

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Last Name:

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Email Address:

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Payment Method

Amount:

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Payment Method:

Credit Card

Payment Information

Name on Checking Account:

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9 Digit Routing Number:

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Bank Account Number:

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Name:
Address
City, State, Zip

Pay To: Independence Capital Recovery Amount: : : 000 Routing Number Account Number Check Number

Name on Card:

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Zip Code:

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Card Number:

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Expiration Date

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Security Code:

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Please Verify Your Information

Reference Number:

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Name:

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Email Address:

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Payment Method:

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Account Payment Amount:

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BY CLICKING ON THE SUBMIT PAYMENT BUTTON, I AGREE TO THE TERMS AND CONDITIONS OF USING MY CREDIT OR DEBIT CARD AS A PAYMENT METHOD AND I AUTHORIZE Independence Capital Recovery TO PROCESS A CHARGE FOR THE DOLLAR AMOUNT ENTERED ABOVE.

I hereby authorize Independence Capital Recovery to debit my debit or credit card in the amount specified above as payment to my account with Independence Capital Recovery for a single account, which will be processed pursuant to the terms of Regulation E; Electronic Funds Transfers of the Federal Reserve System.

I hereby electronically consent to and authorize my signature to the funds transfer authorization. I also agree that I am authorized user of the credit or debit card account that I have provided and that I am authorized to make payment on this account.

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I Agree to the terms and conditions above