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| First Name | Last Name | ||
| Phone | |||
| Address | City | ||
| State | Zip code | ||
| Bank Name | Bank Phone | ||
| Bank Address | Bank City | ||
| Bank State | Bank Zip Code | ||
| Account # | Routing # | ||
| Amount $ | Check Number | ||
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Use this for any questions or Instructions.
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convenience/processing fees : 3.5% for credit card and or PayPal, $5.00 per check