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PLC:

a005wn

Agency:

city of harrisville treasurer

For:

remote sewer and receiving funds

Phone:

989-724-6666

Address:

200 5th street,p o box 278
harrisville, michigan 48740

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*Name:

Middle:

*Last:

*Phone Number:

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

*Service Address 1:

*Account #1:

*Account #1 Amount:

Service Address 2:

Account #2:

Account #2 Amount:

Service Address 3:

Account #3:

Account #3 Amount:

Service Address 4:

Account #4:

Account #4 Amount:

Comments:

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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