First Name:      

Last Name:      

Your Email Address:

Home Phone:      

Cell Phone:      

Street Address:       Apt #:

City:       State:       Zip Code:

Card Type (please check one)    Visa     Mastercard     Discover

Card Number:       Expiration Date (month/year): /

Security Code (last three digits located on back of card):

Payment Amount: $     Is this payment for (please check one):    Legal Fees     Expenses

I authorize Reliance Legal Services to charge my credit card for the amount listed above.

Signature: __________________________________________________________