Do not email this form.

Audit and Agreed Upon Procedure (AUP) Credit Card Form

Payment Type: VISA MC AMEX DISC

Account Number:

Expiration Date: V-Code: Need Receipt(Y/N):

3 digit # on back (far right)

Name as it appears on the card: Fax Number for Receipt:

Mailing Address:
(area code)
City: State: ZIP Code:

Phone:

Signature:

Fiscal Year Description Unit Price Total Amount State Use Only
County, City, Township $175.00 2010
Recreation Commission, Special Districts, All Others $175.00 2010

USD, Community College, All Other Educational Institutions $100.00 2010

Rural Water Districts $100.00 2010
Total $0.00

Provide Name(s) of Municipality Submitting AUP or Audit Filing Fee

State Use Only

Date Received: ____________________ Dept. Fund Budget Unit Program Account Total
Date to Fiscal Services:____________________
Clerk I.D.: 85
Authorization No.: _______________________ 1730803000 2033 1850 01806 420100

Options for Submitting Credit Card Form:

Provide Name of Municipality Submitting Audit Fee(s) Fax to: 785.296.1477
Providing the municipality name helps us to know to which Mail to: Municipal Services Team
municipality we should apply the fee(s). This is especially true when 700 SW Harrison, Suite 300
multiple audit fees are being submitted. Topeka KS 66612

Questions: Call 785.296.8083

Note: When sending the audit report by electronic means, please mention Roger Basinger
in the email that the audit fee(s) have been/will be paid by credit card.

revised 7/31/13