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PLC:

a00374

Agency:

fallon paiute shoshone tribe

For:

water payments

Phone:

775-423-6075

Address:

565 rio vista drive
fallon, nevada 89406

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*Account Holder Name:

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*Last:

*Account #:

Notes:

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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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