Payment Authorization Form

Secure Credit Card / Checking Account Authorization

Please complete this form to authorize a payment to Amaral Law, PLLC. All information is transmitted securely and stored in compliance with data protection standards.

Your payment information is encrypted and secure. We only store the last 4 digits of your card/account number.

Your Information

Full Name *

Email Address *

Phone Number

Payment Method

Authorization Details

Authorized Amount ($) *

Payment Frequency

Payment Description (what is this payment for?)

Billing Address

Street Address *

Apt / Suite / Unit

City *

State *

ZIP Code *

Electronic Signature

Please sign in the box below using your mouse or finger

Terms & Authorization

I authorize Amaral Law, PLLC to charge/debit the account listed above for the amount specified. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Amaral Law, PLLC in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. I certify that I am an authorized user of this account and that I will not dispute this payment with my bank or credit card company, so long as the transaction corresponds to the terms indicated in this authorization form.

I agree to the terms and authorize this payment *

Someone Detained by ICE?

Payment Authorization Form