Legal Case Debit Order Authorization Form
Complete this form to authorize debit order billing for your legal case and provide the details needed to set up the payment schedule.
Client and Case Information
Client Full Name
*
First Name
Middle Name
Last Name
Preferred Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Legal Case / Reference Number
*
Case Name or Matter Description
*
Attorney / Firm Handling the Matter
*
Debit Order and Billing Setup
Debit Order Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Payment Frequency
*
Please Select
Weekly
Biweekly
Monthly
One-time initial debit
Custom schedule
Debit Amount
*
Preferred Debit Day/Date
Billing Reference or Invoice Number
Billing Instructions and Special Notes
Additional Billing Instructions
Preferred Debit Timing
Please Select
On due date
1 business day after due date
Before due date
Flexible/As needed
Other
Alternate Billing Contact
First Name
Middle Name
Last Name
Special Case or Payment Instructions
If a Debit Fails, Please
Please Select
Retry on next business day
Contact me first
Follow the firm’s billing process
Hold until corrected instructions are received
Other
Submit Authorization
Should be Empty: