CHANGE TO PAYMENT PLAN

In order to adjust your payment plan, you MUST fill out this form and return it to us, at least 48 hours before the next scheduled payment. Failure to do so, may result in additional fees being added to your case. You may email the form to jorge@atlantislaw.com, drop it off at our office, or mail it to 9330 Base Line Rd, Ste. 201, Rancho Cucamonga, CA 91701.

Billing Information

Client Name:
Billing Address:
Billing City:
Billing State:
Billing Zip Code:

Payment Information

Payment Option:
Card Number:
Security Code:
Expiration Date:

Payment 1

Payment Date:
Payment Amount:

Payment 2

Payment Date:
Payment Amount:

Payment 3

Payment Date:
Payment Amount:

Payment 4

Payment Date:
Payment Amount:

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