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PLC:

a004l5

Agency:

lake durango water authority

For:

utility payments

Phone:

970-247-4062

Address:

p o box 657
durango, colorado 81302

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*Customer's Name:

Middle:

*Last:

*Account #:

*Billing Address:

*City:

*State:

*Zip:

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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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