HomeMy WebLinkAboutProffer Payment 241 Ezra LnFREDERICK COUNTY PLANNING AND DEVELOPMENT
107 N. Kent St. Suite 202 Winchester, VA 22601
One Time Credit Card Payment Authorization Form
Frederick County imposes a Surcharge of 2.5% for the use of Credit Cards
NO CHARGE FOR DEBIT
Please complete the information below:
CARDHOLDER NAME
ADDRESS (Z r
SIGNATURE DATE
f L I
Please accept payment for the following feted below:
0
Description
Codes
Amount
Sale of Planning Booklets
(PC01)
Sale of GIS Mapping
(IODL)
Miscellaneous Items
(2009)
Bond Management Fees
(BMFEES)
Zoning Applications
(ZASP)
Septic Hauler Permit
(10FY)
Septic Hauler Permit
(10FY)
Sewage Installation
(10FZ)
Residential Pump & Haul
�� Shor`F�zlrnig
(10GA)
0 r 9 � � 0
3-01 o -
1T
Subtotal
$ 1
2.5% Surcharge +
$
Total
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