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PLC:

a0066d

Agency:

town of st armand

For:

water/sewer

Phone:

518-891-3189

Address:

1702 nys route 3
bloomindale, new york 12913

*Required Field

Payment Information

*Account Holder Name:

Middle:

*Last:

*Account # 1:

* Account # 1 Amount:

Account # 2:

Account # 2 Amount:

Account # 3:

Account # 3 Amount:

Email:

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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