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ard No. <br />~y 13 00 ~ <br />z Agency 7 e Type 9 <br />t <br />2 :a <br />DIVISION OF ACCOUNTS AND CONTROL <br />DELINQUENT ACCOUNTS WORK SHEET <br />G - 031 - `~~ I <br />to Account Number xs zz <br />TB IVU V (, -`6~I -~ (~ ~ <br />3 , ,~, •~n `.rr <br />za Address Lrine~, One <br />~i~a~.ifrti~ , <br />W <br />x 7 C~y, State + r <br />g•I I 1 I <br />az Date a7 n Set Next u <br />Promised Action Date to <br />, <br />st <br />doo.o aro B5 F~ F---I <br />za glance Due :9 7o Date Last 7s 7s Ad'ustment+z Cr <br />Statement To Balance <br />I I <br />Recipient of Service If Dilferent eo <br />sz Address Line Two col <br />8 G a0 I I <br />+e Zip s r Telephone s9 r:o Are <br />II Applicable <br />l I I I 1 I I I~ ~ f~ I__ _ I <br />+• +S +6 +7 +e +9 67 691 CI I 70 I rl~~'7l <br />1st 2nd 3rd 4th 5th 6th Amt. Comm. Status Assignment or <br />Letter Action Adjustment bisp. Transler Code <br />I I <br />~, ~ x 7 Date of Birth /Employer s s <br />I <br />' ~ 8 z7 !iM''~ Relerence st <br />i <br />9• <br />~ xa Note for Next Monthly Collections Report <br />A'. 17 PS 76 z7 CBR 7n 7t OMVR 7+ <br />ss <br />7s AC 7e <br />sz <br />Relerence <br />l~ Reference col <br />E <br />Fbrrrrr AC 460+ <br />Line 6,9 and Ais for Central Collection Use Only <br />