Please fill in all the mandatory RED fields, exactly as they appear on your check,
and then use your browser's print button to print it.
Then FAX the printed form to 712.258.2184. You may then use your "back" button to return to our site.

Your Email Address:
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  Second Name, if applicable

 Your Street Address

  Your City, State, Zip

  Your Daytime Phone
 Bank Name

Bank Branch ( Only if indicated on your check )
Bank Street Address
Bank City, State, Zip
Bank Phone Number
Check Number    
  
Fractional Code    
Example: 44-77/4346 01    
 
DATE: Actual Submission 
Date  
 Pay to the order of: ---Mills-Shellhammer-Puetz & Associates---    Amount:$
    Pay Exactly Example: Thirty nine dollars and 95/100
 Memo:
       Routing #                  Account #
  


 

 
Routing and Account Numbers are found at the very bottom of your check.
Sample of Routing #:      Sample of Account #:  
Comments:
   After Printing, please sign on the box to the left.
your payment CAN NOT be processed without your signature.
My signature authorizes Mills-Shellhammer-Puetz & Associates to use the above information to generate a VirtualCheck for the Order Total. This authorization is for this transaction only.  I understand Mills-Shellhammer-Puetz & Associates will send a duplicate voucher receipt of the VirtualCheck draft upon my request. We CAN NOT process your order without your signature here.
 

     

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