800-284-0100

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  (*Required Field)
Payor Information Payment Information
*Company: *BG&B Account #:
*Your Name: *Check #:

Address:		 *Check Date:
Payment Type:
  # of Payments:
  Day of Deposit:
*Daytime Phone:   Payment Amount:
    *Payment Total:
    *Creditor Name:
Bank Information
*Transit/ABA #/ Routing #:
*Bank Name:
*City/State/Zip: *Main Phone #:
*Account #: *Name on Account:
I hereby authorize Baker, Govern & Baker to process a check by phone for the above amount.
Disclosure Notice

Baker, Govern & Baker, Inc. represents the creditor and your checks will be made payable to BG&B on behalf of your creditor and deposited into our client trust account for proper invoice application and remittance to your creditor. In certain cases, we may not process payments without prior verbal authorization obtained from you directly even after you have submitted this payment form. If you have any questions, please call our offices at (954) 749-6944.