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PLC:

a00428

Agency:

city of lamoure

For:

utility

Phone:

701-883-5957

Address:

p. o. box 215
lamoure, north dakota 58458

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*Name on Bill:

Middle:

*Last:

*Address:

*City:

*State:

*Zip:

Phone #:

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

Account #:

Payment Amount

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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