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PLC:

a002di

Agency:

village of freeport

For:

utilities

Phone:

616-765-3808

Address:

209 s state street
freeport, michigan 49325

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*Name:

Middle:

*Last:

*Account #:

*Address:

*City:

*State:

*Zip:

Phone Number:

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

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Payment Amount :

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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