Payment Remittance Form

Payment Remittance Form
Please remit all payments to this address:
1234 ABC Pkwy; Unit A Lexington, KY. 11111 Attn: Remit Department C/O
Kyle D Brown Phone: (222) 222-2222
Sender/Payer Information
Company Name:
Company Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Account Manager's Name:*
First NameLast Name
Phone Number
Email Address:*
Email
Receiver/Payee Information
Name
First NameLast Name
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Payment Details
Payment Amount $
Purpose of Payment
Payment Method
CheckBank TransferCredit CardOther
Click to upload Files*
Max Total Upload Size: 500MB
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Please include any additional comments or notes related to this payment.
Should be Empty: