This invoice has been paid.

ID: {{receipt.Id}}

Email: {{receipt.Email}}

Bill To:

{{receipt.BillToAddress.Address.Street1}} , {{receipt.BillToAddress.Address.Unit}} {{receipt.BillToAddress.Address.City}}, {{receipt.BillToAddress.Address.StateOrProvince}} {{receipt.BillToAddress.Address.PostalCode}}

Ship To:

{{receipt.ShipToAddress.Address.Street1}} , {{receipt.ShipToAddress.Address.Unit}} {{receipt.ShipToAddress.Address.City}}, {{receipt.ShipToAddress.Address.StateOrProvince}} {{receipt.ShipToAddress.Address.PostalCode}}

INVOICE DETAILS

Date Paid: {{receipt.DatePaid | date:'MM/dd/yyyy'}}

Invoice #: {{receipt.InvoiceNumber}}

Invoice Total: {{receipt.InvoiceTotal | currency}} {{receipt.Credits | currency}}

PAYMENT INFORMATION

Payment Method: {{payment.PaymentMethod}}

Total Paid: {{payment.Total | currency}}

INVOICE SUMMARY

Item

Qty

Price Per Unit

Total

Payment(s) Applied: {{receipt.Credits | currency}}

Discount(s): {{receipt.Discounts | currency}}

Balance Due: {{receipt.BalanceDue | currency}} {{0 | currency}}

In the past year has this organization operating under this policy purchased, acquired, merged with or bought the assets of another Ohio organization?

Yes

Did this involve all or part of the organization?

All

Part

Name of the prior organization

Prior organization's policy number, if known

Date of purchase

In the next two years, does this organization plan to acquire all or part of another Ohio operation or the assets of another operation?

Yes

Do you plan to purchase all or part of the organization?

All

Part

Name of the organization

Organization's policy number, if known

Payment Information

BILLING INFORMATION

First Name *

Last Name *

Address 1 *

Address 2

City *

State

Zip *

Credit Card ACH

Payment Type

Name on Card

Card Number

Exp Date (MMYY)

CSV

Bank Name

Name on Account

Routing Number

Account Number

Payment Type