GovPayNet - The Simple Way To Pay

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PLC:

a006gr

Agency:

health and human service of fairbault and martin counties

For:

miscellaneous payments

Phone:

507-238-4757

Address:

115 w. 1st street
fairmont, minnesota 56031

*Required Field

Payment Information

*Customer Name:

Middle:

*Last:

*Account Name:

Claim Number or Invoice Number:

Customer Contact Phone Number:

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

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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