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ard No. <br /> <br />I <br />I <br />~~I l~ 0 0 I ~C <br />~z Agency 7 s ype 9 <br />2 z] <br />3 <br />DIVISION OF ACCOUNTS AND CONTROL <br />DELINQUENT ACCOUNTS WORK SHEET <br />C-o31-`~I <br />to Account Number zt zz <br />TB Nod <br /> <br />st <br /> <br />r <br />~0.00I-~~~ I_--I F-~ <br />x] Balance Due z9 ]o Date Last 7s ]e Ad'ustrrsant~z Cr <br />Statement To Balance <br />rz Recipient of Service II Different eol <br />x7 Address Line One ss I tsz Address Line Two eon <br />I~ ~ <br />q l au~ ~a~ li0 I ~~d I I <br />. x] City.Sute n +e Zip s s7 Telephone svl so Area Code ezi <br /> If Applicable <br />s• I C I -- I J l l l l l l l I-=-I ~-I I- --I I-~ <br />7z Dat! ]7 t t f`IeNt ~JI <br />]a he ~~ ~S ~6 ~7 ~e ~9 67 69 Cf 70 ]I 77 <br />Promised ~ Action bate to 1st 2nd 3rd 4th 5th 6th Amt. Comm. Status Assignment or <br /> Letter Ar•tion Adjustment Disp. Transfer Code <br />~ It7 <br />Date of Birth /Employer <br />ss <br />sz <br />Reference <br />B <br />z7 ~':,.. Reference st <br />I I <br />Isz Reference <br />9' <br />~ z7 Note for Newt Monthly Collections Report <br />. A•. ] PS ze z7 CBR ]n ]s DMVR ]a ]s AC se <br />corm: AC~76~0~ • Line 6,9 and Ai] for Central Collection Use Only <br />s <br />