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Online Pay By Check Form

Please complete the following form and make sure to record your information accurately. Your checking account will be debited for the transaction amount that you post. Please submit the information only once. This is a one time only transaction. Any questions, please call our office at 800-648-0446.
Check number to be used:
Check date:
Account holder information:
Bank information:
Amount of this transaction?
Bank Transit, Routing or ABA #:
Checking account number:
Please post any comments or instructions you might have here:
You grant authorization to theXchange to debit your checking account for the amount as indicated above:
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