BHA SECURE
PAYMENT FORM

You must be using a current version of Microsoft Edge, Google Chrome, Opera, Safari, or Android Browser to set up future payments. It will let you enter them but they will not process from any other browser.

 
If you would like to pay your account using a DEBIT or CREDIT CARD, please provide the following information.  Please note that all fields are required.

Reference #
Please enter the Reference # found on the letter you received from us.  If you do not know your Reference #, please contact us at 1-(877)-852-7255.
Account Information
First Name
Last Name
Street
City State
Zip
Home Phone Example: 555-123-4477
Email
Payment Information

Card Type

  Visa
  MasterCard
  Discover
Card Holder's Name
First Middle Initial Last Name
Card Holder's Address
Street
City State
Zip
Card Number
Expiration Date Security Code
 
Month Year

This is the three digit number found on the back of your card.

You must be using a current version of Microsoft Edge, Google Chrome, Opera, or Android Browser to set up future payments. It will you enter them but they will not process from any other browsers including Interent Explorer, Firefox, and Opera.

Payment for Today. Amount $

Next Payment date: Amount $
Next Payment date: Amount $
Next Payment date: Amount $
Next Payment date: Amount $
Next Payment date: Amount $
Next Payment date: Amount $

We will contact you with any issues at the phone or email listed above!

*By submitting this form, I AUTHORIZE Bryant Hodge & Associates to make a charge to my Credit/Debit Card using the information that I have provided.

Bryant Hodge & Associates
Monday - Saturday 9:00 AM - 9:00 PM
18 North Main Street - Rochester, New Hampshire 03867
FAX: 207-226-0098          TOLL FREE: 1-(877)-852-7255
 



Contact us

373 South Willow St Suite 121 Manchester, NH 03103
Call Us at 877-852-7255
EMAIL Us

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