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					  For 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.
 Type of credit card:                                                                                                                   Total Amount Due:
                                                                                                                                        3% Convenience Fee:
                               Name on card:
    Visa              Discover
                               Billing Address:
    Mastercard                                                                                                                          Total Credit Card Fee:
                                                                                                                                        3% ConvenienceCharge:

Card #:                                                                                                                                 Total Credit Card
                                                                                                                                        Total Amount Due:Charge:

Expiration Date:                                                  CVN # : ___________                                                  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
CVN on American Express cards is usually four digits.
                                                                                                                                     Signature:

                                                                                     p       Keep top portion for your records            p

                                                                                     q     Detach and return with your payment            q




                                                                                                                                    Name:           ____________________________________
      Acct.#:                   ____________________________________                                                                Address:        ____________________________________
      Year(s):                  ____________________________________                                                                                ____________________________________
      Tax Type:                 ____________________________________                                                                                ____________________________________
      Taxing District:          ____________________________________                                                                                ____________________________________


ADD 3% CONVENIENCE FEE TO THE AMOUNT DUE WHEN PAYING BY CREDIT CARD.
 Type of credit card:                                                                                                                   Total Amount Due:
                                                                                                                                        3% Convenience Fee:
                               Name on card:
    Visa              Discover
                               Billing Address:
    Mastercard                                                                                                                          3% Convenience Fee:
                                                                                                                                        Total Credit Card Charge:


Card #:                                                                                                                                 Total Credit Card
                                                                                                                                        Total Amount Due:Charge:

Expiration Date:                                                   CVN # : ___________
                                                                                                                                       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
CVN on American Express cards is usually four digits.
                                                                                                                                     Signature:

				
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