BY CLICKING ON THE SUBMIT PAYMENT BUTTON, I AGREE TO THE TERMS AND CONDITIONS OF USING MY CREDIT OR DEBIT CARD AS A PAYMENT METHOD AND I AUTHORIZE COLLECT NORTHWEST TO PROCESS A CHARGE FOR THE DOLLAR AMOUNT ENTERED ABOVE.

I hereby authorize Collect Northwest to debit my debit or credit card in the amount specified above as payment to my account with Collect Northwest for a single account, which will be processed pursuant to the terms of Regulation E; Electronic Funds Transfers of the Federal Reserve System.

I hereby electronically consent to and authorize my signature to the funds transfer authorization. I also agree that I am authorized user of the credit or debit card account that I have provided and that I am authorized to make payment on this account.