BHA SECURE
PAYMENT FORM


If you would like to pay your account using a PERSONAL or BUSINESS CHECK, please provide the following information.  Should you need assistance finding your bank or account information on your check, please see the sample check at the bottom of this page. 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
Best Phone Example: 555-123-4477
Email

Payment Information

  Check Amount  Check Number  Date (mm/dd/yyyy)
$

Account Holder (as shown on Check)

Name

Street Address
City
State  
 Zip Code
Bank Information (as shown on Check)
Bank Name
Street Address
City
State   
Zip Code
MICR Information
Bank Routing Number
Your Account Number

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 bank account using the information that I have provided.

There will be a $35 Fee for all returned checks.

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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