Form 521 - Non-Withheld Tax Payment Stub For Local Earned Income Tax Page 2

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A Service Fee will be added to your NOVUS Card
A Service Fee will be added to your NOVUS Card
TRANSACTION AMOUNTS
SERVICE FEE
TRANSACTION AMOUNTS
SERVICE FEE
$
00.00 - $ 500.00
$
5.00
$
00.00 - $ 500.00
$
5.00
$ 500.01 - $ 1,000.00
$ 12.00
$ 500.01 - $ 1,000.00
$ 12.00
$ 1,000.01 - $ 2,000.00
$ 23.00
$ 1,000.01 - $ 2,000.00
$ 23.00
$ 2,000.01 - $ 3,000.00
$ 38.00
$ 2,000.01 - $ 3,000.00
$ 38.00
$ 3,000.01 - and up
$ 50.00
$ 3,000.01 - and up
$ 50.00
Fees are subject to change without notice.
Fees are subject to change without notice.
CREDIT CARD INFORMATION
CREDIT CARD INFORMATION
WE ACCEPT DISCOVER/NOVUS CARD ONLY
WE ACCEPT DISCOVER/NOVUS CARD ONLY
_ _ _ _ - _ _ _ _ - _ _ _ _ - _ _ _ _
_ _ _ _ - _ _ _ _ - _ _ _ _ - _ _ _ _
ACCOUNT NUMBER
ACCOUNT NUMBER
CARD EXPIRES ____/____
CARD EXPIRES ____/____
TAX AMOUNT $
.
TAX AMOUNT $
.
SIGNATURE
SIGNATURE

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