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ard No. DIVISION OF ACCOUNTS AND CONTROL <br />DELINQUENT ACCOUNTS WORK SHEET <br />I3~1 130 C~F~ ~- 31-$I H <br />z Agency z e Type s to Account Number zs zz <br />TB <br />~ a~~ ~ I~~~ f ; ~ -~ f~ <br />z] Balance Due z9 3o Date Last 3s 3s Ad'ustment~z Lr <br />Statement To Balance <br />Z I '~ y-~er ~ Gam ~u ens Tic I I I <br />z] Debtor's Name IL st, First) st sz Recipient of Service II Different eo <br />3 .. ~.. ~ .~.r <br />z] Address Line One <br />I <br />4 I ~~u~1ar , C~. I <br />73 itY. State ~ <br />~ g•I 1 I 1 l I I I <br />]z Date ]z 3e Sep t Next ~~ <br />Promised Action Date to <br />ss I Isz Address Line Two aol <br />Bj~~~? ~ I g y i- y 15a I! 303 :I <br />~a Zip sz s3 Telephone 59 so Arer a Code ez~ <br />If Applicable <br />I I I I I I I~ <br />~a +s +e a~ ~e gel e3 69 Cr ro n n <br />1st 2nd 3rd 4th 5th 6th Amt. Comm. Status Assignment or <br />Letter Action Adjustment Disp. Transfer Code <br />7 <br />z 3 Oate of Bnth /Employer s t sz <br />1 ~- <br />~ 8 z3 Reference st Isz <br />9e <br />' z] Note for Next Monthly Collections Report <br />r A- z] PS zc zr CBR yn 3t OMVR s< ss AC se <br />b <br />~ Form: AC~/6~0~ • Line 6 ,9 and A is for Central Collection Use Only <br />Reference <br />so <br />e <br />e <br />