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ard No. <br />i <br />t <br />i <br />1 <br />I <br />I <br />i <br />I <br />~y ~ o0 <br />z Agency 7 s ype s <br /> <br />2 <br />st <br />3 t \J , A V I i <br />xaJ/~ I Ad(d/r~ess Line One ss ///111... ~/~ r Address Line Two ao <br />4 1 1 V Q~~ l~ a LJ~ I ~I~ ~ I ~~ <br />is City, State •7 ae Zip sz ss Telephone s9 so Area Code exi <br />If Applicable <br />g•I __I I I I I I I I I I ICJ L_~ I I l_ ___ _ I <br />az Date s7 xs Set Next a ~ie es ~e n ~e •9 sa 69I I Cr l f 7oI fn7al <br />Promised Action Date to 1st 2nd 3rd 4th 5th 6th Amt. Comm. Status Assignment or <br />Letter Action Adjustment Disp. Transler Code <br />~ Ixs <br />Date of Birth /Employer <br />st <br />z3 glance Due z9 so Date Last as sa Ad'ustmantax Cr <br />Statement To Balance <br />l I <br />sx Recipient of Service If Different eo <br />sz <br />Reference <br />ea <br />E3 zs ~.Y?h~''•~' Reference ss <br />9• <br />zs Note for Next Monthly Collections Report <br />A'~ <br />zs PS zb <br />•• <br />Fgrme AC~7 a~0a <br />n CBR an st DMVR ~a ~s AC ~e <br />DIVISION OF ACCOUNTS AND CONTROL <br />DELINQUENT ACCOUNTS WORK SHEET <br />to~ AO~ItNu~lr xt xx <br />TB C~.O. No . C -ay - l-~c~ <br />s z Reference e n <br />• Line 6 ,9 and A is for Central Collection Use Only <br />r <br />