Form Ir - Mt. Healthy Income Tax Return - 2009 Page 3

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Page 3
1.
CIRCLE ONE:
MASTERCARD
VISA
2.
ACCOUNT NUMBER (16 DIGITS)
____________________________________________________________________
3.
EXPIRATION DATE:
____________________________________________________________________
4.
AMOUNT TO BE PAID:
$___________________________________________________________________
5.
YOUR SIGNATURE FOR AUTHORIZATION:
___________________________________________________________

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