Nebraska Child Support Payment Center
Remittance Form
P.O. Box 82890, Lincoln, NE 68501
Customer Service: 1-877-631-9973
Fax: 402-471-1193
Important Note:
Use this form each time you remit a payment.
Employer Name
Contact Name
Address
City
State
Zip
Telephone Number
Fax Number
Employer FEIN (FTIN)
Email
Check #
Employee Name
SSN
Case Number
Date Paid
Dollar Amount
Employee #1 Name
Employee #1 SSN
Employee #1 Case Number
Employee #1 Date Paid
Employee #1 Dollar Amount
Employee #2 Name
Employee #2 SSN
Employee #2 Case Number
Employee #2 Date Paid
Employee #1 Dollar Amount
Employee #3 Name
Employee #3 SSN
Employee #3 Case Number
Employee #3 Date Paid
Employee #3 Dollar Amount
Employee #4 Name
Employee #4 SSN
Employee #4 Case Number
Employee #4 Date Paid
Employee #4 Dollar Amount
Employee #5 Name
Employee #5 SSN
Employee #5 Case Number
Employee #5 Date Paid
Employee #5 Dollar Amount
Total Amount: $
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