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You are agreeing to pay $ plus a Fee of $ (%) for a Total of $.

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By checking the box to the left, you are indicating that you give Dallam-Hartley Counties Hospital District authorization to process the above payment of $.

By checking the box to the left, you are indicating that you give Dallam-Hartley Counties Hospital District your authorization to process the payments as outlined in the payment schedule above using the payment method listed above. To revoke your authorization you must contact Dallam-Hartley Counties Hospital District.

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