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PLC:

a001u9

Agency:

city of potwin

For:

utilities

Phone:

620-752-3422

Address:

207 n randall,p o box 265
potwin, kansas 67123

*Required Field

Payment Information

*Name:

Middle:

*Last:

Business Name:

Service Address:

*Account #:

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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