<h1>One Time Payment</h1>
<hr />
<form method="post" action="{SELF}">
<input type="hidden" name="data[past_due]" value="{PAST_DUE}">
<input type="hidden" name="data[current_balance]" value="{CURRENT_BALANCE}">
{MESSAGE}
<h2>Payment Information:</h2>
<table class="bTable">
<tr>
  <td>Payment Method:</td>
  <td><select name="data[payment_method]">{PAYMENT_METHOD}</select><a href="/billing/add_pm.php?data[pm_type]=0"> Add credit card</a></td>
</tr>
<tr>
  <td>Payment Amount:</td>
  <td><input type="radio" name="data[payment_opt]" value="0" {PO_0}> Past Due: ${PAST_DUE}<br /><input type="radio" name="data[payment_opt]" value="1" {PO_1}> Current Balance (including past due): ${CURRENT_BALANCE}<br /><input type="radio" name="data[payment_opt]" value="2" {PO_2}> Other Amount $<input type="text" name="data[payment_amount]" value="{PAYMENT_AMOUNT}" size="5"></td>
</tr>
<tr>
  <td>Payment Date:</td>
  <td><input type="text" name="data[payment_date]" value="{PAYMENT_DATE}" size="5"></td>
</tr>
<tr>
  <td></td>
  <td align="right"><input type="submit" name="data[uap]" value="Next"></td>
</tr>
</table>
</form>