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Submission: On March 13 via manual from US — Scanned from DE
Submission: On March 13 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
<form id="paymentForm" aria-label="payment-form">
<div class="row">
<div class="col-12 col-md-7 form-group">
<div class="ap-money-wrapper">
<div class="ap-money-prefix">
<div class="ap-mask-input-wrapper float-label labeled required" data-testid="ap-masked-wrapper"><label for="amountField" class="ap-mask-input-label" data-testid="ap-masked-label">Payment Amount</label><input type="text"
class="ap-money-textbox " id="amountField" label="Payment Amount" name="amountField" placeholder="" required="" data-testid="ap-masked-input" value=""></div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-12 form-group">
<div class="ap-text-input-wrapper float-label labeled" data-testid="ap-input-text"><label for="reference" class="ap-text-input-label" data-testid="ap-input-label">Reference</label><input type="text" id="reference" label="Reference"
name="reference" aria-required="false" aria-disabled="false" value=""></div>
</div>
</div>
<div class="row"></div>
<div class="row">
<div class="col-12">
<h2>Payment Method</h2>
</div>
</div>
<div class="ap-accordion Card " data-testid="Card-test-id">
<div class="ap-accordion-header" id="card-id" aria-expanded="false" aria-controls="card-content-id" tabindex="0">
<div class="ap-accordion-container">
<div class="ap-accordion-check "></div>
<div class="ap-accordion-headline">
<p class="ap-accordion-title">Card</p>
<div class="ap-accordion-subtitle">Debit and Credit accepted.</div>
</div>
</div>
<div class="ap-accordion-images-container"><img src="/assets/packs/media/paymentpagereact/visa-e5f49cb3.svg" class="ap-accordion-images" alt="Visa"><img src="/assets/packs/media/paymentpagereact/mastercard-66458aad.svg"
class="ap-accordion-images" alt="Master Card"><img src="/assets/packs/media/paymentpagereact/amex-b7bf1ae4.svg" class="ap-accordion-images" alt="American Express"><img src="/assets/packs/media/paymentpagereact/discover-04c123d6.svg"
class="ap-accordion-images" alt="Discover"></div>
</div>
<div class="expanded-content" id="card-content-id" data-testid="accordion-content" aria-hidden="true" role="region" aria-labelledby="card-id">
<div class="row">
<div class="col-12 form-group">
<div class="ap-text-input-wrapper float-label labeled" data-testid="ap-input-text"><label for="cardName" class="ap-text-input-label" data-testid="ap-input-label">Name on Card</label><input type="text" id="cardName" label="Name on Card"
name="cardName" aria-required="false" aria-disabled="false" value=""></div>
</div>
<div class="col-12 col-sm-7 form-group">
<div class="ap-labeled-hosted-input"><label class="inline-label" id="card-number-label">Card Number</label>
<div id="cc_number" data-testid="cc_number" class="hosted-wrap col-10" aria-labelledby="card-number-label"><iframe sandbox="allow-scripts allow-same-origin" src="https://cdn.affinipay.com/hostedfields/1.4.0/field_1.4.0.html"></iframe>
</div>
<div class="input-card-icon generic-card" role="img" alt="credit cards logo" title="credit card logo"></div>
</div>
</div>
<div class="col-5 col-sm-2 form-group">
<div class="ap-labeled-hosted-input"><label class="inline-label" id="cvv-label">CVV</label>
<div id="cvv" data-testid="cvv" class="hosted-wrap " aria-labelledby="cvv-label"><iframe sandbox="allow-scripts allow-same-origin" src="https://cdn.affinipay.com/hostedfields/1.4.0/field_1.4.0.html"></iframe></div>
</div>
</div>
<div class="col-7 col-sm-3 form-group">
<div class="ap-mask-input-wrapper float-label labeled required" data-testid="ap-masked-wrapper"><label for="cardExpiration" class="ap-mask-input-label" data-testid="ap-masked-label">Exp. Date</label><input type="text" class=""
id="cardExpiration" label="Exp. Date" name="cardExpiration" placeholder="" required="" data-testid="ap-masked-input" value=""></div>
</div>
<div class="billing-address row ">
<div class="col-12">
<h3>Billing Address</h3>
</div>
<div class="col-12 form-group">
<div class="ap-text-input-wrapper float-label labeled required" data-testid="ap-input-text"><label for="cardBillingAddress" class="ap-text-input-label" data-testid="ap-input-label">Address</label><input type="text" id="cardBillingAddress"
label="Address" name="cardBillingAddress" required="" aria-required="true" aria-disabled="false" value=""></div>
</div>
<div class="col-12 form-group">
<div class="ap-text-input-wrapper float-label labeled" data-testid="ap-input-text"><label for="cardBillingAddress2" class="ap-text-input-label" data-testid="ap-input-label">Address 2</label><input type="text" id="cardBillingAddress2"
label="Address 2" name="cardBillingAddress2" aria-required="false" aria-disabled="false" value=""></div>
</div>
<div class="col-12 col-sm-6 form-group">
<div class="ap-text-input-wrapper float-label labeled" data-testid="ap-input-text"><label for="cardBillingCity" class="ap-text-input-label" data-testid="ap-input-label">City</label><input type="text" id="cardBillingCity" label="City"
name="cardBillingCity" aria-required="false" aria-disabled="false" value=""></div>
</div>
<div class="col-12 col-sm-6 form-group state-dropdown">
<div class="ap-select-wrap floating-label"><label id="downshift-0-label" for="downshift-0-toggle-button" class="ap-select-label">State</label><button id="downshift-0-toggle-button" aria-haspopup="listbox" aria-expanded="false"
aria-labelledby="downshift-0-label downshift-0-toggle-button" data-testid="combobox" class="ap-select-toggle" type="button">
<div class="ap-selected-text"></div>
</button>
<ul id="downshift-0-menu" role="listbox" aria-labelledby="downshift-0-label" tabindex="-1" class="ap-options"></ul>
</div>
</div>
<div class="col-12 col-sm-6 form-group">
<div class="ap-text-input-wrapper float-label labeled required" data-testid="ap-input-text"><label for="cardBillingZip" class="ap-text-input-label" data-testid="ap-input-label">Zip / Postal Code</label><input type="text"
id="cardBillingZip" label="Zip / Postal Code" name="cardBillingZip" required="" aria-required="true" aria-disabled="false" value=""></div>
</div>
<div class="col-12 col-sm-6 form-group">
<div class="ap-select-wrap floating-label selected"><label id="downshift-1-label" for="downshift-1-toggle-button" class="ap-select-label">Country</label><button id="downshift-1-toggle-button" aria-haspopup="listbox" aria-expanded="false"
aria-labelledby="downshift-1-label downshift-1-toggle-button" data-testid="combobox" class="ap-select-toggle" type="button">
<div class="ap-selected-text">United States</div>
</button>
<ul id="downshift-1-menu" role="listbox" aria-labelledby="downshift-1-label" tabindex="-1" class="ap-options"></ul>
</div>
</div>
<div class="col-12 form-group ">
<div class="ap-text-input-wrapper float-label labeled" data-testid="ap-input-text"><label for="cardEmail" class="ap-text-input-label" data-testid="ap-input-label">Receipt Email</label><input type="text" id="cardEmail"
label="Receipt Email" name="cardEmail" aria-required="false" aria-disabled="false" value=""></div>
</div>
</div>
</div>
<div class="payment-summary-subtotals">
<div class="payment-summary-description">
<div data-testid="summary-payment-amount">Payment</div>
<div data-testid="subtotal">$0.00</div>
</div>
</div>
<div class="row">
<div class="col-12 text-center text-md-right"><button class="ap-button ap-primary-button submitButton" aria-disabled="false" aria-label="" aria-describedby="" type="submit" data-testid="submit-btn-card">Pay $0.00</button></div>
</div>
<div class="row">
<div class="col-12 payment-disclaimer">By clicking on the Pay Button, you agree to pay the above amount and provide your information to help us process your payment and detect fraud. Please see our
<a href="https://lawpay.com/terms/privacy/" rel="noopener noreferrer" target="_blank">Privacy Policy</a> for more information on our data practices.</div>
</div>
</div>
</div>
<div class="ap-accordion Pay Later " data-testid="Pay Later-test-id">
<div class="ap-accordion-header" id="pay later-id" aria-expanded="false" aria-controls="pay later-content-id" tabindex="0">
<div class="ap-accordion-container">
<div class="ap-accordion-check "></div>
<div class="ap-accordion-headline">
<p class="ap-accordion-title">Pay Later</p>
<div class="ap-accordion-subtitle">
<p class="affirm-as-low-as" data-page-type="product" data-amount="0">Pay over time on amounts $150+ with <span class="__affirm-logo __affirm-logo-blue __ligature__affirm_full_logo__ __processed">Affirm</span>.
<a class="affirm-modal-trigger" aria-label="Learn More - Learn more about Affirm Financing (opens in modal)" href="javascript:void(0)">Learn more</a></p>
<p>0% interest for qualified clients. See example payment plans for more information.</p>
</div>
</div>
</div>
<div class="ap-accordion-images-container"><img src="/assets/packs/media/paymentpagereact/affirm-logo-2e1f7c35.svg" class="ap-accordion-images" alt="Affirm"></div>
</div>
<div class="expanded-content" id="pay later-content-id" data-testid="accordion-content" aria-hidden="true" role="region" aria-labelledby="pay later-id">
<div class="affinipay-loanjs-wrapper row" test-id="loan-js">
<div class="col-12"><span>For your convenience, we are offering financing for your service provider fees with flexible options through Affirm. You can begin your loan application below. It is quick and secure, and you’ll get a real-time
decision.</span></div>
<div class="col-12 mt-2"><span>Start by entering your basic information:</span></div>
<div class="col-xs-12 col-6 form-field">
<div class="ap-text-input-wrapper float-label labeled required" data-testid="ap-input-text"><label for="firstName" class="ap-text-input-label" data-testid="ap-input-label">First Name</label><input type="text" id="firstName"
label="First Name" name="firstName" required="" aria-required="true" aria-disabled="false" value=""></div>
</div>
<div class="col-xs-12 col-6 form-field">
<div class="ap-text-input-wrapper float-label labeled required" data-testid="ap-input-text"><label for="lastName" class="ap-text-input-label" data-testid="ap-input-label">Last Name</label><input type="text" id="lastName" label="Last Name"
name="lastName" required="" aria-required="true" aria-disabled="false" value=""></div>
</div>
<div class="col-12 form-field">
<div class="ap-text-input-wrapper float-label labeled required" data-testid="ap-input-text"><label for="email" class="ap-text-input-label" data-testid="ap-input-label">Email Address</label><input type="text" id="email" label="Email Address"
name="email" required="" aria-required="true" aria-disabled="false" value=""></div>
</div>
<div class="col-12 mt-2"><span>Your application will be processed exclusively through Affirm and its lending partners, not your service provider.</span></div>
<div class="col-12 align-right continue-button-wrapper"><button class="ap-button ap-primary-button" aria-disabled="false" aria-label="" aria-describedby="" type="submit">Begin Process</button></div>
<div class="align-left secondary-text"><span><sup>*</sup>US consumers only. Affirm is not available to entity customers who would use Affirm financing for business or commercial purposes. Payment options through Affirm are provided by these
lending partners: </span><span><a href="https://www.affirm.com/lenders" target="_blank" rel="noreferrer">affirm.com/lenders</a><a href="https://www.affirm.com/terms" target="_blank" rel="noreferrer">See terms</a></span></div>
</div>
</div>
</div>
</form>Text Content
JAVASCRIPT IS DISABLED! Please enable Javascript in your browser, then refresh the page. Javascript is required to run this website. Gill Ragon Owen PA 425 W. Capitol Ave. Ste. 3801 Little Rock, AR 72201 (501) 376-3800 carolyn@gill-law.com INVOICE PAYMENT Payment Detail Gill Ragon Owen PA Payment Amount Reference PAYMENT METHOD Card Debit and Credit accepted. Name on Card Card Number CVV Exp. Date BILLING ADDRESS Address Address 2 City State Zip / Postal Code Country United States Receipt Email Payment $0.00 Pay $0.00 By clicking on the Pay Button, you agree to pay the above amount and provide your information to help us process your payment and detect fraud. Please see our Privacy Policy for more information on our data practices. Pay Later Pay over time on amounts $150+ with Affirm. Learn more 0% interest for qualified clients. See example payment plans for more information. For your convenience, we are offering financing for your service provider fees with flexible options through Affirm. You can begin your loan application below. It is quick and secure, and you’ll get a real-time decision. Start by entering your basic information: First Name Last Name Email Address Your application will be processed exclusively through Affirm and its lending partners, not your service provider. Begin Process *US consumers only. Affirm is not available to entity customers who would use Affirm financing for business or commercial purposes. Payment options through Affirm are provided by these lending partners: affirm.com/lendersSee terms Our system uses SSL encryption technology, which is the same technology banks use to protect sensitive information.