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1 Your account

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2 Cardholder

3 Card

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4 Authorize & sign

Authorization. I ask Concord Financial Solutions, billing office for the creditor on this account, to charge the card I entered today, one time, in the amount shown. The charge appears as CONCORD FINANCIAL.

Acknowledgment. The balance on the account reference above is mine and is owed as of today, and I am paying voluntarily. So long as the charge matches what is written here, I will raise any question with Concord Financial Solutions rather than disputing it with my bank or card issuer.

Returned payments. A payment that is reversed or charged back leaves the balance unresolved, and any fee charged to us for it may be billed to me. We will call to arrange a replacement before any further step.

Questions. For a receipt or any question about this payment, contact Concord Financial Solutions at (888) 971-7429 or hello@concord-financial.com, Monday – Friday, 8:00 AM – 5:00 PM.

I, ________, authorize Concord Financial Solutions to charge $0.00 to the card entered above, one time, on November 7, 2026, for account reference ________.

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Your card is charged once, when you press Pay.