<h1 class="title">Report a payment</h1><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><p class="content-text"> Report a paymentFirst Name *Last Name *Account No *Payment Type *CheckCredit CardOtherTransaction Date *Amount *Comments * VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>: </p>
