ACH Payment | H.J. Pertzborn Plumbing & Fire Protection

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HJP Account Number*

Number of Invoices*

Invoice Number*

Payment Amount*

Invoice #2*

Invoice #2 Payment Amount*

Invoice #3*

Invoice #3 Payment Amount*

Invoice #4*

Invoice #4 Payment Amount*

Invoice #5*

Invoice #5 Payment Amount*

Memo

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Phone*

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Account holder Name * Account Number * Routing Number * Account Type * Check Type *

PAYMENT TERMS AND CONDITIONS*

AUTHORIZATION
By checking the "I accept the Terms and Conditions" checkbox below I authorize my bank to debit my specified account for the amount of my payment. This is a one-time payment which will occur on the next business day or as soon as practical thereafter. If my payment cannot be completed for any reason, including insufficient funds or error in the information which I submitted, I will retain the same liability, which is my sole responsibility, for payment as though I had not attempted to make the payment. I also understand that additional fees and penalties may be collected to the extent of applicable law.

RECEIPT
A receipt can be printed after payment is accepted which may serve as evidence of payment. If an email address is provided during the payment process, a receipt will be emailed to you after the payment is processed.

CONTACT
If for any reason you wish to make a change to the payment after submission, please contact H.J. Pertzborn Plumbing & Fire Protection for assistance at 608-256-3900

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