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PLC:

a002cs

Agency:

city of fruitland

For:

miscellaneous payments

Phone:

563-264-1748

Address:

104 sand run road, po box 97
fruitland, iowa 52749

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*Name:

Middle:

*Last:

*Address:

*City:

*State:

*Zip:

*Date of event:

(Month / Day / Year)

*Resident Type:

*Rental Type:

*Phone #:

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

Payment Amount

Payment Amount :

Subtotal:

$0.00

Total:

$0.00

Billing Information

*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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