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PLC:

a00591

Agency:

lee county sheriffs office

For:

fees

Phone:

319-372-1152

Address:

2530 255th street
montrose, iowa 52639

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*Name:

Middle:

*Last:

Suffix:

Date of Birth:

(Month / Day / Year)

*Phone #:

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

*Type of Service:

*Description of Payments/Civil Number:

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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