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Billing Information

*First Name

*Last Name

*Billing Address

*Billing City

*Billing State

*Billing Zip

*Day Time Phone Number

*Contact Email

Account Information

*Account Number from Statement:

*Amount Of Payment  $

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Refund Policy: The Firm will apply any payments made towards legal fees and costs incurred. If the Firm’s services are terminated, the Firm will apply any payments made towards legal fees and costs incurred through the date of termination. Any excess amount will be refunded to the payor within 30 days after the date of the termination.