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PLC:

a0025g

Agency:

antelope county sheriff's office

For:

reports

Phone:

402-887-4148

Address:

1102 l street
neligh, nebraska 68756

*Required Field

Payment Information

*Name:

Middle:

*Last:

*Report Type:

*Date of Accident/incident:

(Month / Day / Year)

Mail or Email report to:

*Contact #:

(### - ### - ####)

Payment Amount

Payment Amount :

Subtotal:

$0.00

Total:

$0.00

Billing Information

*First Name:

Middle Initial:

*Last Name:

*Billing Address:

*City:

*State/Province:

*Zip:

*Country:

*Phone Number:

*Credit/Debit Card:

(enter the full card number without any dashes or spaces)

*Expiration Date:

*Card Security Number:

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