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ard No. DIVISION OF ACCOUNTS AND CONTROL <br />DELINQUENT ACCOUNTS WORK SHEET <br />M L R 1> , GF , I r=- - o fib- ~ 1 I ~____+ <br />z Agency 7 B Type 9 to Account Number zl zz <br />TB <br />1 <br />~ Trnida.~~iasi~c /~'liyin9il'.tG, I <br />2 z3 Debtor's Name (Las ,First) 51 <br />s I Po. ~X 7&3 <br />x3 Address Line One <br />q I Tr7n r ala-.~~ Co 8iCL9 Z- <br />z3 City, State a71 <br />6~ <br />32 Date 37 3B Set Next 43 <br />Promised Action Date to <br />~ z3 Date of Birth /Employer <br />8 z3 ~ Reference <br />51 <br />ZO S~ i I I I I I I <br />z3 Balance Due z9 3o Date Last 3s 3fi Ad'ustment4z Cr <br />Statement To Balance <br />Isz Recipient of Service If Different Bo1 <br />52 <br />Address Line Two <br />Bo <br />ae Zip sz 1s3 Telephone 591 co Arel aCodeezl <br />Ii Applicable <br />~ ~ ~ I I I I~ <br />44 45 46 47 4B 49 63 69 Cr 70 )1 )3 <br />1st 2nd 3rd 4th 5th 6th Amt. Comm. Status Assignment or <br />Letter Action Adjustment Disp. Transfer Code <br />at I sz Reference eo1 <br />s 1 I sz Reference eo <br />9" <br />z3 Note for Next Monthly Collections Report <br />ii A• PS ~~ ~ 3e <br />z3 2fi z7 CBR 3n 31 DMVR a4 35 AC <br />~ Form: AC~7 fi~04 • Line 6,9 and Ais for Central Collection Use Only <br />