stahlherndon-associates.epaypolicy.com
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Submitted URL: http://stahlherndon-associates.epaypolicy.com/
Effective URL: https://stahlherndon-associates.epaypolicy.com/
Submission: On March 27 via manual from US — Scanned from DE
Effective URL: https://stahlherndon-associates.epaypolicy.com/
Submission: On March 27 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
POST /
<form action="/" enctype="multipart/form-data" id="payment-form" method="post" sessionid="" novalidate="novalidate"><input data-val="true" data-val-required="The MakeFieldsReadonly field is required." id="MakeFieldsReadonly" name="MakeFieldsReadonly"
type="hidden" value="False">
<div class="row">
<div class="col-sm-12">
<div class="form-group">
<div class="col-lg-offset-1 col-md-offset-1 col-sm-offset-1 col-lg-2 col-md-2 col-sm-2 col-xs-12 left">
<label for="payer">Payer</label>
</div>
<div class="col-lg-9 col-md-9 col-sm-9 right">
<span class="field-validation-valid" data-valmsg-for="Payer" data-valmsg-replace="true"></span>
<input class="form-control" data-bind="value: payer" data-val="true" data-val-maxlength="The Payer has a maximum length of 150 characters." data-val-maxlength-max="150" data-val-required="The Payer field is required." id="Payer"
name="Payer" placeholder="Payer" required="" type="text" value="">
</div>
</div>
</div>
<div class="col-sm-12">
<div class="form-group email">
<div class="col-lg-offset-1 col-md-offset-1 col-sm-offset-1 col-lg-2 col-md-2 col-sm-2 col-xs-12 left">
<label for="email">Email Address</label>
</div>
<div class="col-lg-9 col-md-9 col-sm-9 right">
<span class="field-validation-valid" data-valmsg-for="EmailAddress" data-valmsg-replace="true"></span>
<input class="form-control" data-bind="value: emailAddress" data-val="true" data-val-email="The Email Address is not properly formatted"
data-val-maxlength="The field Email Address must be a string or array type with a maximum length of '150'." data-val-maxlength-max="150" data-val-required="The Email Address field is required." id="EmailAddress" name="EmailAddress"
placeholder="Email Address" required="" type="text" value="">
</div>
</div>
</div>
<div class="col-sm-12">
<div class="form-group">
<div class="col-lg-offset-1 col-md-offset-1 col-sm-offset-1 col-lg-2 col-md-2 col-sm-2 col-xs-12 left">
<label>Do you have an account number?</label>
</div>
<div class="col-lg-9 col-md-9 col-sm-9 right">
<ul class="nav nav-pills">
<li data-bind="event: { click: function () { TransactionAttribute1842('true'); return false; } }, css: { 'active' : TransactionAttribute1842() == 'true' }" class="active">
<a href="#1TransactionAttribute1842" data-toggle="tab">
<span class="radio-button">
<span></span>
</span>
<span class="tab-name">
Yes
</span>
</a>
</li>
<li data-bind="event: { click: function () { TransactionAttribute1842('false'); return false; } }, css: { 'active' : TransactionAttribute1842() == 'false' }">
<a href="#2TransactionAttribute1842" data-toggle="tab">
<span class="radio-button">
<span></span>
</span>
<span class="tab-name">
No
</span>
</a>
</li>
</ul>
</div>
</div>
</div>
<div class="col-sm-12">
<div class="form-group">
<div class="col-lg-offset-1 col-md-offset-1 col-sm-offset-1 col-lg-2 col-md-2 col-sm-2 col-xs-12 left">
<label>Account Number</label>
</div>
<div class="col-lg-9 col-md-9 col-sm-9 right">
<span class="field-validation-error transaction-attribute-regex-error-msg" style="display:none" data-valmsg-for="TransactionAttribute1843" data-valmsg-replace="true"></span>
<span class="field-validation-error" style="display:none" data-valmsg-for="TransactionAttribute1843" data-valmsg-replace="true">The Account Number field is required.</span>
<input name="TransactionAttribute1843" class="form-control full " data-bind="textInput: TransactionAttribute1843" data-toggle="popover" data-trigger="manual focus" id="TransactionAttribute1843" onblur="validateCustomAttribute(event)"
pattern="(.*?)" placeholder="Account Number" type="text" value="">
</div>
</div>
</div>
<div class="col-sm-12">
<div class="form-group">
<div class="col-lg-offset-1 col-md-offset-1 col-sm-offset-1 col-lg-2 col-md-2 col-sm-2 col-xs-12 left">
<label>Zip Code</label>
</div>
<div class="col-lg-9 col-md-9 col-sm-9 right">
<span class="field-validation-error transaction-attribute-regex-error-msg" style="display:none" data-valmsg-for="TransactionAttribute1844" data-valmsg-replace="true"></span>
<span class="field-validation-error" style="display:none" data-valmsg-for="TransactionAttribute1844" data-valmsg-replace="true">The Zip Code field is required.</span>
<input name="TransactionAttribute1844" class="form-control full " data-bind="textInput: TransactionAttribute1844" data-toggle="popover" data-trigger="manual focus" id="TransactionAttribute1844" onblur="validateCustomAttribute(event)"
pattern="(.*?)" placeholder="Zip Code" type="text" value="">
</div>
</div>
</div>
</div>
<div class="row" id="invoices">
<div class="col-sm-12">
<div class="form-group">
<div class="col-lg-offset-1 col-md-offset-1 col-sm-offset-1 col-lg-2 col-md-2 col-sm-2 col-xs-12 left">
<label>Invoices</label>
</div>
<div class="col-lg-9 col-md-9 col-sm-9 col-xs-12 right">
<div data-bind="visible: AreAnyAttributeValuesEmptyOrInvalid()" style="display: none;">
<label>Please fill in the fields above correctly to view your open invoices.</label>
</div>
<div style="display: none;" data-bind="visible: !AreAnyAttributeValuesEmptyOrInvalid() && invoiceSearches() > 0" id="searching-invoices">
<i class="fas fa-spinner fa-spin"></i> <label>Searching for open invoices...</label>
</div>
<div style="" data-bind="visible: invoiceSearches() == 0 && !invoiceSearchFailed() && !AreAnyAttributeValuesEmptyOrInvalid() && fullInvoiceList().length == 0 && invoices().length == 0"
id="searching-invoices">
<label>No invoices were found<span data-bind="visible: hasAccount() && invoicesPayerName(), text: ' for ' + invoicesPayerName()" style="display: none;"> for null</span>.</label>
</div>
<div style="display:none" data-bind="visible: !invoiceSearchFailed() && isFilteringAllInvoices()">
<label>No results found. Please adjust your search criteria.</label>
</div>
<div style="display:none" data-bind="visible: invoiceSearches() == 0 && invoices().length > 0 && invoicesPayerName() && hasAccount()">
<label>Displaying invoices for <span data-bind="text: invoicesPayerName"></span></label>
</div>
<div style="display:none" data-bind="visible: invoiceSearchFailed() && !AreAnyAttributeValuesEmptyOrInvalid() && invoiceSearches() == 0 && fullInvoiceList().length == 0 && invoices().length == 0"
id="searching-invoices">
<label data-bind="text: invoiceSearchResponseStatusCode() != 429 ? 'Unable to retrieve invoices.' : 'Requests have exceeded maximum allowed. Please try again in a moment.'">Unable to retrieve invoices.</label>
</div>
<!--ko if:model.enableAutopay-->
<div class="autopay-options-block">
<div class="disable-option" id="autopay-disable-option" style="display:none" data-bind="visible: invoiceSearches() == 0 && autoPaySubscriptionId() != null && hasAccount()">
<p>AutoPay is currently enabled.</p>
<a class="disable-btn" data-bind="visible: autoPayCancelable(), click: CancelAutoPaySubscription" style="display: none;">Disable</a>
<div class="learn-more"><a href="#" data-bind="click: openAutopayModal">Learn more</a></div>
</div>
</div>
<!--/ko-->
<div data-bind="visible: fullInvoiceList().length > 10" style="display: none;">
<input type="text" id="invoice-search" name="invoice-search" class="form-control" placeholder="Search Invoices" data-bind="textInput: invoiceSearchText">
</div>
<div class="invoice-list-wrapper" data-bind="visible: invoiceSearches() == 0 && fullInvoiceList().length > 0" style="display:none;">
<table class="table table-header">
<thead>
<tr>
<th>Invoice
<i class="invoiceSort fas fa-sort" data-bind="css: { 'fa-sort': (currentSort() != 'Id' && currentSort() != 'DescendingId'), 'fa-sort-down': (currentSort() == 'DescendingId'), 'fa-sort-up': (currentSort() == 'Id')}, click: function(){sortInvoices('Id')}"></i>
</th>
<th>Name
<i class="invoiceSort fas fa-sort" data-bind="css: { 'fa-sort': (currentSort() != 'Name' && currentSort() != 'DescendingName'), 'fa-sort-down': (currentSort() == 'DescendingName'), 'fa-sort-up': (currentSort() == 'Name')}, click: function(){sortInvoices('Name')}"></i>
</th>
<th>Due Date
<i class="invoiceSort fas fa-sort" data-bind="css: { 'fa-sort': (currentSort() != 'DueDate' && currentSort() != 'DescendingDueDate'), 'fa-sort-down': (currentSort() == 'DescendingDueDate'), 'fa-sort-up': (currentSort() == 'DueDate')}, click: function(){sortInvoices('DueDate')}"></i>
</th>
<th>Amount
<i class="invoiceSort fas fa-sort" data-bind="css: { 'fa-sort': (currentSort() != 'Amount' && currentSort() != 'DescendingAmount'), 'fa-sort-down': (currentSort() == 'DescendingAmount'), 'fa-sort-up': (currentSort() == 'Amount')}, click: function(){sortInvoices('Amount')}"></i>
</th>
<th>
<button type="button" class="btn btn-primary btn-block add-all-invoices-btn" id="invoices-add-all" data-bind="click: addAll, style: { background: addAllClicked() ? 'red' : '' }, text: addAllText, visible: invoices().length > 0"
style="display: none;">+ Add All</button>
</th>
</tr>
</thead>
</table>
<div>
<div class="invoices-list" data-bind="css: { 'invoices-scrollable': invoices().length > 10 }">
<table class="table table-body">
<tbody data-bind="foreach: invoices"></tbody>
</table>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="payment-amount row">
<div class="col-sm-12">
<div class="form-group">
<div class="col-lg-offset-1 col-md-offset-1 col-sm-offset-1 col-lg-2 col-md-2 col-sm-2 col-xs-12 left">
<label for="amount">Total of Selected Invoices</label>
</div>
<div class="col-lg-9 col-md-9 col-sm-9 right">
<span class="field-validation-valid" data-valmsg-for="Amount" data-valmsg-replace="true"></span>
<input class="form-control" data-bind="value: formatAmount(amount(), 'USD')" id="FormattedAmount" name="FormattedAmount" type="text" value="" readonly="" tabindex="-1"><input data-bind="numeric, value: amount" data-val="true"
data-val-number="The field Amount must be a number." data-val-range="The Amount must be greater than 0." data-val-range-max="10000000" data-val-range-min="0.01" data-val-required="The Amount field is required." id="Amount" name="Amount"
required="" type="hidden" value="0.00">
</div>
</div>
</div>
</div>
<div class="row payment-type">
<div class="col-sm-12">
<div class="form-group clearfix">
<div class="col-lg-offset-1 col-md-offset-1 col-sm-offset-1 col-lg-2 col-md-2 col-sm-2 col-xs-12 left">
<label for="payment-type">Payment Type</label>
</div>
<div class="col-lg-9 col-md-9 col-sm-9 right clearfix">
<div class="large-device">
<label for="paymentType" class="payment-ui-card clearfix">
<input type="radio" class="form-control payment-radio" name="paymentType" data-bind="click: function() {setPaymentType('Ach'); return true;}, value: 'Ach', checked: paymentMethod" value="Ach">
<div class="payment-ui-card-wrapper">
<div class="ui-card-header ">
<img src="/images/echeck-icon.png" class="img-responsive" alt="credit-card-icon">
<h3 class="text-center">ACH</h3>
</div>
<div class="ui-card-details">
<div class="ui-card-row">
<span class="row-label">Amount</span>
<span class="info" data-bind="text: formatAmount(amount(), 'USD')">$0.00</span>
</div>
<div class="ui-card-row fees">
<span class="row-label">Fee</span>
<span class="info" data-bind="text: amount() > 0 ? formatAmount(payerAchFee(), 'USD') : 'Add Invoices'">Add Invoices</span>
</div>
<div class="ui-card-row totals">
<span class="row-label" data-bind="text: enableScheduledPayments() ? 'Each Payment' : 'Total'">Total</span>
<span class="info" data-bind="text: formatAmount(amount() > 0 ? achTotal() : 0, 'USD')">$0.00</span>
</div>
</div>
<div class="radio-button">
<span></span>
</div>
</div>
</label>
</div>
<div class="small-device">
<div class="options-row clearfix">
<label for="mobilePaymentType" class="payment-ui-card clearfix">
<input type="radio" class="form-control payment-radio" name="mobilePaymentType" data-bind="click: function() {setPaymentType('Ach'); return true;}, value: 'Ach', checked: paymentMethod" value="Ach">
<div class="radio-button">
<span></span>
</div>
<div class="ui-card-header">
<img src="/images/echeck-icon.png" class="img-responsive" alt="ach-icon">
<h3 class="text-center">ACH</h3>
</div>
</label>
</div>
<div class="payment-ui-card-wrapper left-tab" data-bind="visible: paymentMethod() == 'CreditCard'" style="display: none;">
<div class="ui-card-details">
<div class="ui-card-row">
<span class="row-label">Amount</span>
<span class="info" data-bind="text: formatAmount(amount(), 'USD')">$0.00</span>
</div>
<div class="ui-card-row fees">
<span class="row-label">Fee</span>
<span class="info" data-bind="text: amount() > 0 ? formatAmount(payerCreditCardFee(), 'USD') : 'Add Invoices'">Add Invoices</span>
</div>
<div class="ui-card-row totals">
<span class="row-label" data-bind="text: enableScheduledPayments() ? 'Each Payment' : 'Total'">Total</span>
<span class="info" data-bind="text: formatAmount(amount() > 0 ? creditCardTotal() : 0, 'USD')">$0.00</span>
</div>
</div>
</div>
<div class="payment-ui-card-wrapper right-tab" data-bind="visible: paymentMethod() == 'Ach'">
<div class="ui-card-details">
<div class="ui-card-row">
<span class="row-label">Amount</span>
<span class="info" data-bind="text: formatAmount(amount(), 'USD')">$0.00</span>
</div>
<div class="ui-card-row fees">
<span class="row-label"> Fee </span>
<span class="info" data-bind="text: amount() > 0 ? formatAmount(payerAchFee(), 'USD') : 'Add Invoices'">Add Invoices</span>
</div>
<div class="ui-card-row totals">
<span class="row-label" data-bind="text: enableScheduledPayments() ? 'Each Payment' : 'Total'">Total</span>
<span class="info" data-bind="text: formatAmount(amount() > 0 ? achTotal() : 0, 'USD')">$0.00</span>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="payment-info row">
<div class="col-sm-12">
<div class="form-group">
<div class="col-lg-offset-1 col-md-offset-1 col-sm-offset-1 col-lg-2 col-md-2 col-sm-2 col-xs-12 left">
<label for="payment-info">Payment Information</label>
</div>
<div class="col-lg-9 col-md-9 col-sm-9 right" data-bind="visible: paymentMethod() == 'CreditCard'" style="display: none;">
<div class="form-group">
<div data-bind="visible: tokenPublicId() == 'newCreditCard' || creditCardTokenCount() == 0 || true" style="">
<div class="row">
<div class="col-lg-12">
<span class="field-validation-valid" data-valmsg-for="CardAccountHolder" data-valmsg-replace="true"></span>
<input autocomplete="off" class="form-control" data-val="true" data-val-maxlength="The Name on Card has a maximum length of 40 characters." data-val-maxlength-max="40" id="CardAccountHolder" name="CardAccountHolder"
placeholder="Name on Card" type="text" value="">
</div>
</div>
<div class="row">
<div class="col-lg-12">
<span class="field-validation-valid" data-valmsg-for="CardNumber" data-valmsg-replace="true"></span>
<span class="ccInput">
<input autocomplete="off" class="form-control" data-bind="textInput: cardNumber" data-val="true" data-val-maxlength="The Card Number has a maximum length of 16 characters." data-val-maxlength-max="16" id="CardNumber"
maxlength="16" name="CardNumber" placeholder="Credit Card Number" type="text" value="">
<!-- ko if: cardType() == 'DISCOVER' || cardType() == undefined --><i class="fab fa-2x fa-cc-discover"></i><!-- /ko -->
<!-- ko if: cardType() == 'AMEX' || cardType() == undefined --><i class="fab fa-2x fa-cc-amex"></i><!-- /ko -->
<!-- ko if: cardType() == 'MASTERCARD' || cardType() == undefined --><i class="fab fa-2x fa-cc-mastercard"></i><!-- /ko -->
<!-- ko if: cardType() == 'VISA' || cardType() == undefined --><i class="fab fa-2x fa-cc-visa"></i><!-- /ko -->
</span>
</div>
</div>
<div class="row">
<div class="col-lg-6 col-md-6 col-sm-6">
<input autocomplete="off" class="form-control" data-val="true" data-val-number="The field Month must be a number." id="Month" name="Month" placeholder="Month (MM)" type="text" value="">
</div>
<div class="col-lg-6 col-md-6 col-sm-6">
<input autocomplete="off" class="form-control" data-val="true" data-val-number="The field Year must be a number." id="Year" name="Year" placeholder="Year (YYYY)" type="text" value="">
</div>
</div>
<div class="row">
<div class="col-lg-6 col-md-6 col-sm-6">
<input autocomplete="off" class="form-control" data-val="true" data-val-maxlength="The CVC has a maximum length of 4 characters." data-val-maxlength-max="4" data-val-regex="The CVC can only contain numbers."
data-val-regex-pattern="^\d{3,4}$" id="CVC" name="CVC" placeholder="CVC" type="text" value="">
</div>
<div class="col-lg-6 col-md-6 col-sm-6">
<input autocomplete="off" class="form-control" id="PostalCode" maxlength="6" name="PostalCode" placeholder="Postal Code" type="text" value="">
</div>
</div>
<div class="row" data-bind="if: paymentMethod() != 'Ach'"></div>
</div>
</div>
</div>
<div class="col-lg-9 col-md-9 col-sm-9 right" data-bind="visible: paymentMethod() == 'Ach'">
<div>
<div class="tab-pane" id="2a">
<div class="form-group">
<div data-bind="visible: tokenPublicId() == 'newAch' || achTokenCount() == 0 || true" style="">
<div class="row">
<div class="col-lg-12">
<span class="field-validation-valid" data-valmsg-for="BankAccountHolder" data-valmsg-replace="true"></span>
<input autocomplete="off" class="form-control" data-val="true" data-val-maxlength="The Account Holder has a maximum length of 40 characters." data-val-maxlength-max="40" id="BankAccountHolder" name="BankAccountHolder"
placeholder="Bank Account Holder" type="text" value="" required="required">
</div>
</div>
<div class="row">
<div class="col-lg-12">
<span class="field-validation-valid" data-valmsg-for="RoutingNumber" data-valmsg-replace="true"></span>
<input autocomplete="off" class="form-control" data-original-title="Routing Number" data-toggle="popover" data-trigger="manual focus" data-val="true" data-val-maxlength="The Routing Number has a maximum length of 9 characters."
data-val-maxlength-max="9" id="RoutingNumber" name="RoutingNumber" placeholder="Routing Number" type="text" value="" required="required">
</div>
</div>
<div class="row">
<div class="col-lg-12">
<span class="field-validation-valid" data-valmsg-for="AccountNumber" data-valmsg-replace="true"></span>
<input autocomplete="off" class="form-control" data-original-title="Account Number" data-toggle="popover" data-trigger="manual focus" data-val="true" data-val-maxlength="The Account Number has a maximum length of 17 characters."
data-val-maxlength-max="17" data-val-minlength="The Account Number has a minimum length of 3 characters." data-val-minlength-min="3" data-val-regex="The account number can contain only digits." data-val-regex-pattern="\d+"
id="AccountNumber" name="AccountNumber" placeholder="Account Number" type="text" value="" required="required">
</div>
</div>
<div class="row">
<div class="col-lg-12">
<input autocomplete="off" class="form-control" data-original-title="Confirm Account Number" data-toggle="popover" data-trigger="manual focus" data-val="true" id="ConfirmAccountNumber" name="ConfirmAccountNumber"
placeholder="Confirm Account Number" type="text" value="" required="required">
</div>
</div>
<div class="row" data-bind="if: paymentMethod() == 'Ach'">
<div class="col-md-12">
<div class="checkbox" data-bind="click: ShowSignInPopup">
<input autocomplete="off" class="form-control" id="SavePaymentOption" name="SavePaymentOption" type="checkbox" value="true"><input name="SavePaymentOption" type="hidden" value="false">
<label for="SavePaymentOption">Save my bank account for future use</label>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row notes clearfix">
<div class="col-sm-12">
<div class="form-group">
<div class="col-lg-offset-1 col-md-offset-1 col-sm-offset-1 col-lg-2 col-md-2 col-sm-2 col-xs-12 left">
<label>Notes</label>
</div>
<div class="col-lg-9 col-md-9 col-sm-9 right">
<fieldset>
<span class="field-validation-valid" data-valmsg-for="Comments" data-valmsg-replace="true"></span>
<textarea class="notes-textarea" cols="20" id="Comments" name="Comments" placeholder="Notes (optional)" rows="5"></textarea>
</fieldset>
</div>
</div>
</div>
</div>
<!--ko if:model.enableAutopay-->
<div class="row autopay" style="display:none" data-bind="visible: autoPaySubscriptionId() == null && hasAccount()">
<div class="col-sm-12">
<div class="form-group">
<div class="col-lg-offset-1 col-md-offset-1 col-sm-offset-1 col-lg-2 col-md-2 col-sm-2 col-xs-12 left">
<label>AutoPay</label>
</div>
<div class="col-lg-9 col-md-9 col-sm-9 right">
<label class="switch">
<input class="form-control" data-bind="click: ShowSignInPopup" data-val="true" data-val-required="The EnableAutoPay field is required." id="autopay-enable" name="EnableAutoPay" tabindex="-1" type="checkbox" value="true"><input
name="EnableAutoPay" type="hidden" value="false">
<span class="slider round"> </span>
</label>
<label for="autopay-enable"> Enable AutoPay for future invoices. <span class="learn-more"><a href="#" data-bind="click: openAutopayModal">Learn more</a></span>
</label>
</div>
</div>
</div>
</div>
<!--/ko-->
<div class="row payment-confirmation">
<div class="col-sm-12">
<div class="form-group">
<div class="col-lg-offset-1 col-md-offset-1 col-sm-offset-1 col-lg-2 col-md-2 col-sm-2 col-xs-12 left"></div>
<div class="col-lg-9 col-md-9 col-sm-9 right">
<p class="agreement">
<label id="standard-disclaimer" class="" for="confirm-disclaimer">
<label id="confirm-disclaimer-label" for="confirm-disclaimer"> By clicking "Send", I authorize Stahl Herndon & Associates to debit my account. <span data-bind="visible: payerFee() > 0" style=""> I understand that <span
data-bind="visible: enableScheduledPayments() == false">this payment</span>
<span data-bind="visible: enableScheduledPayments" style="display: none;">each of the <span data-bind="text: numberOfPayments(), visible: numberOfPayments() > 0" style="display: none;"></span> payments</span> includes a <span
data-bind="text: formatAmount(payerFee(), 'USD')">$4.00</span> fee assessed by <a href="http://epaypolicy.com" target="_blank">ePayPolicy</a>. </span>
</label>
</label>
</p>
<p>
</p>
<div class="g-recaptcha" data-sitekey="6Ld0RzwUAAAAAOpZnxpJZrI-V-GMXXDHAmEpfEJV">
<div style="width: 304px; height: 78px;">
<div><iframe title="reCAPTCHA"
src="https://www.google.com/recaptcha/api2/anchor?ar=1&k=6Ld0RzwUAAAAAOpZnxpJZrI-V-GMXXDHAmEpfEJV&co=aHR0cHM6Ly9zdGFobGhlcm5kb24tYXNzb2NpYXRlcy5lcGF5cG9saWN5LmNvbTo0NDM.&hl=de&v=vpEprwpCoBMgy-fvZET0Mz6L&size=normal&cb=tp7uu0uzji5w"
width="304" height="78" role="presentation" name="a-io2nplqtmrsa" frameborder="0" scrolling="no"
sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox"></iframe></div><textarea id="g-recaptcha-response" name="g-recaptcha-response"
class="g-recaptcha-response" style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea>
</div><iframe style="display: none;"></iframe>
</div>
<input type="hidden" class="hiddenRecaptcha required" name="hiddenRecaptcha" id="hiddenRecaptcha">
<br>
<p></p>
<input type="submit" name="submitButton" class="btn btn-success" value="Send" id="Submit" data-bind="css: { 'inactive' : !confirmDisclaimer() }, click: submitForm">
<input type="hidden" id="PaymentMethod" name="PaymentMethod" data-bind="value: paymentMethod" value="Ach">
<input type="hidden" id="EnableScheduledPayments" name="EnableScheduledPayments" data-bind="value: enableScheduledPayments" value="false">
<input type="hidden" id="ScheduledPaymentsEndOption" name="ScheduledPaymentsEndOption" data-bind="value: scheduledPaymentsEndOption" value="Never">
<input type="hidden" id="TokenPublicId" name="TokenPublicId" data-bind="value: submitTokenPublicId">
<input type="hidden" id="DuplicateTransactionReceiptUrl" name="DuplicateTransactionReceiptUrl" data-bind="value: duplicateTransactionReceiptUrl">
<input type="hidden" id="TransactionAttribute1842" name="TransactionAttribute1842" data-bind="value: TransactionAttribute1842" value="true">
<input id="PreAuthorizationCode" name="PreAuthorizationCode" type="hidden" value="">
<input data-val="true" data-val-date="The field PreAuthorizationDate must be a date." id="PreAuthorizationDate" name="PreAuthorizationDate" type="hidden" value="">
<input data-val="true" data-val-number="The field ClientNotificationId must be a number." id="ClientNotificationId" name="ClientNotificationId" type="hidden" value="">
<input name="__RequestVerificationToken" type="hidden" value="Dxe86G4OMVbM6LS5Bo4qWyNJ4IDnFQ-gcIHRsnHLRaTP6qJ1Eej_3de114fsVjoa0UuHRKflQXKFOIG71gSG5qzOwuk1">
<input type="hidden" name="attachments" id="attachments" data-bind="value: fileModels" value="[]">
</div>
</div>
</div>
</div>
<div id="bankAccountNumberPopup" style="display: none">
<div><img src="/images/account-number.png"></div>
</div>
<div id="bankRoutingNumberPopup" style="display: none">
<div><img src="/images/routing-number.png"></div>
</div>
</form>Text Content
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