SIPlive: Carbon County Clerk (L.?)

Carbon County Clerk's Office

Business License
751 East 100 North, Suite 1100 - Price, UT 84501
VALYN.PEACOCK@CARBON.UTAH.GOV
435-636-3227

Contact the clerks office prior to payment for exact amount.

Amount:

Item Subtotal:

$0.00

Business Account Number	[1]
Business Name	[1]
Business Account Number	[2]
Business Name	[2]
Business Account Number	[3]
Business Name	[3]
Business Account Number	[4]
Business Name	[4]
Business Account Number	[5]
Business Name	[5]
Business Account Number	[6]
Business Name	[6]
Business Account Number	[7]
Business Name	[7]
Business Account Number	[8]
Business Name	[8]
Business Account Number	[9]
Business Name	[9]
Business Account Number	[10]
Business Name	[10]

Total:

$0.00

Payer's Information

First Name:	Last Name:
Address:
Address:
City:	State/Province:	ZIP/Postal Code:
Phone:
Email:

Payment Information

Method of Payment:

Processing Fee Rates:

Cards: 2.5% ($1.50 min)
(4% for foreign cards)

eCheck (ACH): $0.75

	Update name from Payer's Information
Name of Individual on Checking Account: Name of Individual on Savings Account: Name of Business on Checking Account:
Bank Routing Number:
Bank Account Number:
Confirm Account Number:

Credit Card Number:	(Type number or swipe with cursor in this empty field)
Expiration Date:	/

Cardholder Information (exactly as it appears on your statement)
	Update from Payer's Information
Cardholder's Name:
Billing ZIP/Postal Code:

Please be aware that credit card payments will reflect on your statement as
Carbon UT 800-764-0844 Price UT

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