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Credit Card Payment Authorization

Authorize upfront fees for credit report and appraisal

Secure Form

Demo Mode

This is a demonstration form. In production, this would integrate with Stripe for secure PCI-compliant payment processing. Card numbers are never stored - only secure tokens.

1. Borrower Information

Borrower Name *

Loan Number

2. Loan Officer Information

Loan Officer

Processor

Branch

3. Fee Breakdown

Upfront fees required to process your application

Credit Report Fee

Typical: $50-100

Appraisal Fee

Typical: $400-600

Other Fees

Total Amount$0.00

4. Billing Information

Name on Card *

Billing Address

City

State

ZIP Code

5. Payment Information

Your card information is encrypted and secure

Card Number *

Demo: Use 4111 1111 1111 1111 (Visa) or 5555 5555 5555 4444 (Mastercard)

Expiration Month

Expiration Year

CVV *

3-4 digit security code

visa

mastercard

amex

discover

6. Authorization

I/We authorize EMC Mortgage Capital to charge this credit card for mortgage application fees including credit report fees and appraisal fees in the amount of $0.00.

I/We understand that the appraisal and credit report fees are non-refundable once the appraisal and/or credit report have been ordered.

Note: If you are using a Citibank credit card, there may be additional processing requirements.

I agree to the authorization terms and understand fees are non-refundable

Digital Signature *

By typing your name, you agree this constitutes your legal signature

Date: 12/13/2025