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PLC:

a004no

Agency:

racine county child support division

For:

child support - integration

Phone:

262-636-3493

Address:

1717 taylor avenue
racine, wisconsin 53403

*Required Field

Payment Information

*Non-Custodial Parent Name:

Middle:

*Last:

*Non-Custodial Parent SSN:

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

*Case Identifier:

NOTE: The Case Identifier is the KIDS PIN #

To designate payment to a specific court case enter the Court Case # below.

Court Case #:

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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