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PLC:

a003yk

Agency:

middletown township

For:

school & percapita - manual entry

Phone:

215-945-1777

Address:

2222 trenton road
levittown, pennsylvania 19056

*Required Field

Payment Information

*Bill Number 1:

*Bill Number 1 Amount:

Bill Number 2:

Bill Number 2 Amount:

Bill Number 3:

Bill Number 3 Amount:

Bill Number 4:

Bill Number 4 Amount:

Email Address:

Payment Amount

*Payment Type:

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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