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Open Space Fund

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Name & Address of Person Making Payment

First Name*: Last Name*: Suffix:(MD, Sr., etc)
Address*:     Apt. No.:
Town/City*:     State*:     Zip Code*:
Phone No.*:   -     Ext.:
E-Mail Address*:

Contribution Information

Contribution Amount : $

Bank Information

Bank Routing Number:                    
Re-Enter Bank Routing Number:
Bank Account Number:
Re-Enter Bank Account Number:
Select Checking or Savings Account: Checking     Savings

I authorize the City of Alexandria to debit my bank account, as indicated above, and affirm and attest to the fact that I am authorized to do so. I understand and agree that any mistake or failure of my financial institution to release the authorized amount is solely my responsibility. If there are insufficient funds in my account to pay the authorized amount, I understand and agree that no payment will take place, and a $35 returned check fee will be added to the amount I owe. If I fail to provide accurate account or payment information, I understand that my payment may be delayed or rejected. The City of Alexandria adheres to state and federal privacy laws to protect customer information. All payment information will be treated as confidential, and will only be shared with third parties to the extent required to complete the transaction, to collect a debt, or as otherwise required by law.

This transaction is also subject to the City of Alexandria's web site Legal Notices. For more information about the eChecks service, please contact the City of Alexandria Treasury Division, 301 King Street, Suite 1510, Alexandria, VA 22314, 703.838.4777, payments@alexandriava.gov.

YES, I understand and agree to the above terms. Please submit my payment.
NO, please cancel this payment.