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PLC:

a004ls

Agency:

city of blackduck

For:

utility payments

Phone:

218-835-4803

Address:

8 summit avenue, p o box 380
blackduck, minnesota 56630

*Required Field

Payment Information

*Customer Name:

Middle:

*Last:

City- Blackduck:

State- Minnesota:

Zipcode- 56630:

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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