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ard No. DIVISION OF ACCOUNTS AND CONTROL <br />DELINQUENT ACCOUNTS WORK SHEET <br />3 13 00 ~F I C- 031- vl H <br />z Agency x e Type s to Account Number zt zz <br />TB <br />z3 Balance Due ze ao Oate Last as ae Ad'mtttwnt+x Lr <br />,/~ Statement To Balance <br />~ q I n,~,r ~ CC.m. + <br />i' za Debtor's Name (La t, First) s t sz Recipient of Service If Dif lerent eo <br /> <br />3 ~' ' <br />z~ Address Line One <br />4 1 ~41.~1 0.r ~~ , I <br />z a C ty, State +~ <br />g'L I I I I I I ~ <br />laz Dale l~l l~exl +31 <br />Promised Action Date to <br />st I Isz Address Line Two aoi <br />~~oa I gy i - ~ ~~a I <br />+e Zip sz s~ Telephone sv so Are1 aCode bzl <br />If Applicable <br />++ I +5 I +6 I a/ I +e I +9 I I6~ r _f l )1 p 1 rt 13 <br />1st 2nd 3rd 4th 5th 6th Amt Comm. Sla[us Assignment or <br />Letter Action Adjustment Disp. Transfer Code <br />~ x ~ Date of Birth /Employer s r <br />I <br />8 xa Reference st <br />9~ <br />~ za Note for Newt Monthly Collections Report <br /> <br />,~, <br />sz Reference eo <br />sz <br />Reference <br />e <br />A ,~ PS zc zr CBR ~n ~t DMVR ~~ ~s AC ~a <br />Fnrm: RC 160+ <br />Line 6 , 9 and A it !or Central Collection Use Only <br />