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$25

$50

$75

$100

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Do you want to continue receiving monthly statements *

Yes

No

I understand by checking the box below that I am entering into a monthly recurring monthly payment plan for the balance on my account. I understand when I submit this form, I will receive an email with a link within 24 hours to enter my credit information in a secure server. That payment will be set-up as a recurring payment each month on the same day. I understand that if I need to make a change or cancel a recurring payment I will need to call 435-850-7255 at least 48 hours prior to scheduled payment.

Yes