Payment Form


Please fill out the form below to submit your payment information online.
If you would prefer to make a payment by phone, please call us at 866-696-2120.


Payment Form
Your Information   Bank Information
  * Required
* Our File # 
* First Name 
* Last Name 
* Last 4 of SSN 
* Street Address 
* City 
* State       Your state not listed?
* Zip 
Phone  You may contact me by phone regarding this payment
Email  You may contact me by email regarding this payment
* Payee 

(name of creditor you are paying)
This is an attempt to collect a debt, and any information obtained will be used for that purpose. This communication is from a debt collector.
* Name(s) on Check 
* Bank Name 
Bank City 
* Bank State 
* Bank Routing Number 
* Bank Account Number 
Payment Information
* I am: 
(select one) 
making a one-time payment
offering to set up recurring monthly payments
By submitting this form, I acknowledge and agree that Burton Neil & Associates, P.C. may contact me with respect to this payment.
I understand that this is an offer and subject to approval.