City of Page | Information Request Billing

* Required field

Date: *

Name: *

Email Address: *

Requesting Party: *

Regarding: *

Note: Please check box below and enter amount directed by City Clerks to be paid for information request.

Select	#	Item Description		Amount			Subtotal
	1	Information Request Payment - Enter Dollar Amount					$0.00

Total

$0.00

First Name *

Last Name *

Address *

City *

State *

Zip *

Phone *

Email *

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