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PLC:

a001wd

Agency:

city of edna

For:

utility payments

Phone:

620-922-3841

Address:

209 n delaware,p o box 190
edna, kansas 67342

*Required Field

Payment Information

*Name:

Middle:

*Last:

Business Name:

*Contact Phone #:

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

*Account #1:

*Account #1 Amount:

Account #2:

Account #2 Amount:

Account #3:

Account #3 Amount:

Account #4:

Account #4 Amount:

Notes:

Payment Amount

*Payment Type:

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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