Third Party Billing Form

Third Party Billing Form

Today's Date: 

Your Name: 

Address: 

Contact Number: 

Email : 

At my request, I herby authorize Town of Bancroft to charge the following to my Credit Card:

Property Tax Account Number:  Amount:

Utility Account Number: Amount: 

Other:  Amount: 

Please note that we are unable to accept American Express as a method of payment at this time.

Credit Card Number:  Exipry:  CVV:  (3 digit code on the back of Card)

Cardholder's Name: 

I authorize the Town of Bancroft to charge the credit card indicated in this authorization from. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am the authorizaed user of this credit card. 



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