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PLC:

a002ur

Agency:

city of van horne

For:

utility

Phone:

319-228-8238

Address:

114 main street
van horne, iowa 52346

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*Name:

Middle:

*Last:

Account #:

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City:

State:

Zip:

Payment Amount

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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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