The information that you provide on this form will be used to maintain Sundry Debtors records.The information may be compared with that held by other Council departments, or other organisations, for the purposes of preventing or detecting fraud and in accordance with the Authority's notification under the Data Protection Act 1998.You have rights under this Act (for further information please contact this office on telephone number 0121 303 5524).
Address Line 1
Address Line 2
Address Line 3
(This reference can be found in the top right hand corner of your invoice)
Amount of Invoice to Pay
(Please note pounds (sterling) and pence are required. Minimum amount is £10.00.)