SPRINGDALE TAX COMMISSION 
                                                                              
                                          11700 Springfield Pike 
                                          Springdale Ohio 45246 
                                          Phone: (513) 346-5716 
                                          Fax:    (513) 346-5756  
                                                                              
                                         Credit Card Payment                               Form 
 
                     (To pay by credit card you must complete this form and fax or mail your payment) 
 
                                                                                               Visa             MasterCard     Discover 
 
Name: _________________________________________________ Check One:  __________   _________   _________ 
           Please Print Cardholder Name 
 
Credit 
Card 
Num.:           _________________  -   _________________  - _________________  -  _________________   ( 16 Digits) 
 
                                                                 3 Digit                    Authorized 
Expiration                                                Security                            Payment 
Date:         ____________________       Code :  _________________         Amount :      _$______________________                        
 
Cardholder                                                                                  Daytime 
Signature:  ______________________________________________        Phone #: ____________________________ 
                                         
                                         (Please indicate how payment is to be applied) 
 
Springdale Account #:  ________________                                               Tax  Penalty/Interest       Pay Plan 
 
Tax Year:  ____________                                                     ___________     ___________   ____________ 
 
Tax Year:  ____________                                                     ___________     ___________   ____________ 
 
Tax Year:  ____________                                                     ___________     ___________   ____________ 
 
Tax Year:  ____________                                                     ___________     ___________   ____________ 
 
For Office Use Only