Donation Form

Student Loan Repayment Form

This form enables you to either make a single payment against your student loan, or to set up recurring monthly payments.

You may pay either by direct withdrawal from your bank account, or by charging to your credit card.

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Payment Information

Payment Amount

$50

Type of Payment

One Time PaymentRecurring Monthly

Contact Information

First Name

Last Name

Student Loan Account Number

Address

Address 2

City

State/Province

Zip/Postal Code

Home Phone

Cell Phone

Work Phone

Payment Information

Payment Options

Credit Card Information

Card Holder Name

Card Account Number

Expiration Date

Security Code

Store Account with SafeSave™

Billing Address

Same As Above

Address

City

State/Province

Zip/Postal Code

Privacy Policy
We keep your personal information private and secure. When you make a payment through our site, you provide your name, contact information, payment information, and additional information related to your transaction. We use this information to process your payment and to ensure your payment is correctly credited to your account.

Contact Us: Jewish Children's Regional Service •• P.O. Box 7368, Metairie, LA 70010-7368 •• 504-828-6334 •• [email protected]