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PLC:

a004c0

Agency:

la plata west water authority

For:

water payments

Phone:

970-749-1940

Address:

p o box 631
durango, colorado 81302

*Required Field

Payment Information

*Account Holder Name:

Middle:

*Last:

*Account/Meter #1:

*Account/Meter #1 Amount:

Account/Meter #2:

Account/Meter #2 Amount:

Account/Meter #3:

Account/Meter #3 Amount:

Account/Meter #4:

Account/Meter #4 Amount:

Account/Meter #5:

Account/Meter #5 Amount:

Notes:

Payment Amount

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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