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ard No. <br /> <br />3 - 13 00 <br />x Agenq ~ s Type s <br />2 I <br />:a <br />3 ~.o , <br />xa <br />DIVISION OF ACCOUNTS AND CONTROL <br />,,~~DELtt INQQQ``~~''UENT ACCOUNTS WORK SHEET <br />to~Aco~l1Numbel xt xx <br />TB Iv6 ~ C -$~I -~ Ala <br />ss <br />ess Line One ss <br />9F 50.D0 1 a as $ ~~ ~~ <br />xa Balance Due ze ao Date Last as ae Ad'ustmant,z Cr <br />Statement To Balance <br />rz Recipient of Service It Different col <br />sz Address Line Two eon <br />q l 1 t 41A.1 l ~1' , l i0 I ~ 0 0 I I <br />xa -~ City, State at xe Zip s s3 Telephone sv so Ares a Code ez <br />II Applicable <br />g•~L~ l I I I I I I I~ I I u I _ I <br />1l ax Date at ae Set Next ea ,~ as ee er ee ae ea ev I Cr I I to I frt~~r~i <br />Promised Action Date to 1st 2nd 3rd 4th 5th 6th Amt. Comm. Status Assignment or <br />Leper Action Adjustment Disp. Transfer Code <br />~ ~ 1=' <br />z <br />Reference <br />~ 9 za ~4:~%'~~' Reference st sl z <br />i <br />9' <br />I z~ Note for Next Monthly Collections Report <br />" A~ a~ PS ze n CBR 3n 3t DMVR ~. ss AC se <br />Fgrm: AC ~76~0e • Line 6 ,9 and A is for Central Collection Use Only <br />Date of Birth /Employer <br />st <br />eo <br /> <br />Reference <br />~_- <br />