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PLC:

a0050j

Agency:

milltown village

For:

utility payments

Phone:

715-825-3258

Address:

89 main street west,p o box 485
milltown, wisconsin 54858

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*Name:

Middle:

*Last:

Business Name (if applicable):

*Service Address:

*Account #:

Example: XXX-XXXX-XX

Email Address:

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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