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DEMO Page 6

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Payment Information

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Billing Information

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(as shown on account)
(i.e. 00000-0000)
(i.e. 000-000-0000)

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Account Information

Please select payment type (electronic check or credit card) and enter information for that option.

Checking Account Information
Sample Check

Credit Card Account Information
VISAMasterCardDiscover Order Total (includes the payment(s) that will be remitted to the agency)

Description: State Fines
Id: C99CR120000002
Quantity: 1

Description: State Fines
Id: C99CR120000002
Quantity: 1