DSS PAYMENTS DEV – OnPay.Ongov.Net

DSS-Economic Security Payments

	DSS Payments Form

	Step 1 of 2 50% FormName Client Information (Person for whom you are paying) Client Name* First Middle Last Address* Street Address Address Line 2 City State ZIP Code Email Enter Email Confirm Email Phone* Last 4 digits of your SSN* Card Holder Check here if person making payment is different than client Card Holder Name* First Last Card Holder Address* Street Address Address Line 2 City State ZIP Code Card Holder Email* Enter Email Confirm Email (Email Address Required for Receipt) Card Holder Phone* Add a question or comment Account or Case #* Account or Case # can found on the notice mailed to you. It is located in the upper right hand corner of the letter. Account or Case # can found on the notice mailed to you. It is located in the upper right hand corner of the letter. Program Payment Please enter a payment amount for any of the programs you are paying today. Payments can be made on one or more of the programs listed below Medicaid SNAP/Foodstamps Temporary Assistance Day Care HEAP I Don't Know Other Total $0.00 Credit Card* Discover MasterCard Visa Card Number Expiration Date Security Code Cardholder Name Please review your submission: {all_fields}

Client Information