Credit Card Processing Form - Central Tax Bureau, Pennsylvania
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1For credit card payments please complete the form below with the
Date:
____________________________________
information from the accompanying tax form.
After you have completed each form please be sure to add a 3%
convenience fee to your Total Amount Due, and sign and return both
forms.
This form will not be processed unless the accompanying tax form is
included.
CREDIT CARD PROCESSING FORM
Name:
____________________________________
Acct.#:
____________________________________
Address:
____________________________________
Year(s):
____________________________________
____________________________________
Tax Type:
____________________________________
____________________________________
Taxing District:
____________________________________
____________________________________
ADD 3% CONVENIENCE FEE TO THE AMOUNT DUE WHEN PAYING BY CREDIT CARD.
Total Amount Due:
3% Convenience Fee:
Type of credit card:
Name on card:
Visa
Discover
Billing Address:
3% Convenience Fee:
Mastercard
Total Credit Card Charge:
Total Credit Card Charge:
Total Amount Due:
Card #:
CVN # :
___________
Expiration Date:
I agree to pay a 3% convenience fee to CENTAX (if paying by credit card).
On Mastercard, Visa, and Discover credit cards, the CVN is printed on the back of the card in the signature strip. The CVN is the
last three digits. For American Express cards, the CVN is printed just above the embossed number on the front of the card. The
Signature:
CVN on American Express cards is usually four digits.
p
p
Keep top portion for your records
q
q
Detach and return with your payment
Name:
____________________________________
Acct.#:
____________________________________
Address:
____________________________________
Year(s):
____________________________________
____________________________________
Tax Type:
____________________________________
____________________________________
Taxing District:
____________________________________
____________________________________
ADD 3% CONVENIENCE FEE TO THE AMOUNT DUE WHEN PAYING BY CREDIT CARD.
Total Amount Due:
3% Convenience Fee:
Type of credit card:
Name on card:
Visa
Discover
Billing Address:
3% Convenience Fee:
Mastercard
Total Credit Card Charge:
Total Credit Card Charge:
Total Amount Due:
Card #:
CVN # :
___________
Expiration Date:
I agree to pay a 3% convenience fee to CENTAX (if paying by credit card).
On Mastercard, Visa, and Discover credit cards, the CVN is printed on the back of the card in the signature strip. The CVN is the
last three digits. For American Express cards, the CVN is printed just above the embossed number on the front of the card. The
Signature:
CVN on American Express cards is usually four digits.
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