Pay By Check This communication is from a debt collector. This is an attempt to collect a debt, any information obtained will be used for that purpose. Personal Profile: * Completion of ALL fields is required * Name: * Address: * City: * State: * Zip Code: * Phone Number: Checking Account Information: * Completion of ALL fields is required * List RG Number From Correspondence: * Amount You Wish To Pay: * ACH Check Charge is $5.00 Per Check: * Total Amount of Check: * Name on Check: * Check Number: * Bank Name: * Bank Routing Number: * Checking Account Number: I Hereby authorize The Law Offices of Ross Gelfand, LLC to make a one time electronic debit of my payment via ACH (draft) or other Electronic Funds Transfer (EFT) based on the submission of the information contained herein. I Certify that I am a signer on the account listed above with the authority to grant this authorization. This form supercedes any and all previous authorizations.