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PLC:

a001mc

Agency:

city of browns valley

For:

utility

Phone:

320-695-2110

Address:

19 3rd street south,p o box 334
browns valley, minnesota 56219

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*Name:

Middle:

*Last:

Business Name (if applicable):

*Property Street Address:

Account #:

*Phone #:

(### - ### - ####)

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*Payment Type:

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Subtotal:

$0.00

Total:

$0.00

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*First Name:

Middle Initial:

*Last Name:

*Billing Address:

*City:

*State/Province:

*Zip:

*Country:

*Phone Number:

*Credit/Debit Card:

(enter the full card number without any dashes or spaces)

*Expiration Date:

*Card Security Number:

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