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<br />Card No. DIVISION OF ACCOUNTS AND CONTRO! <br />DELINQUENT ACCOUNTS WORK SHEET <br />z Agency 7 e Type 9 to Account Number zl zz <br />TB <br />1 0 !!~~ L <br />L~,L c~ ~ rv~ q., r~~ n t~ /,~ , z7 Balance Due z9 3o Datl a Last 7sl 7e Adjustmentbz I Cr I <br />J C /`~( 1 V ~v C_V Statement To Balance <br />i <br />Z 23 <br />51 <br />sz <br />z] Address Line One sz Address Line Two <br />3 <br />e <br />a lr -Lc•~,yCZfl !U~~t C C. I G .~ ? I I <br />21 7 City, State 47 ss Zip sz ~ s3 Telephone s9 soso Ares a Code z <br />LL~-- II I I IflApplicable <br />g•L I I _I I ~~F'' I I I I I~ f~ <br />172 D~ 38 Sei Ne%t 93 49 45 46 47 4B 49 6] 69 Cf 70 71 ]3 <br />Promised Action Date to 1st 2nd 3rd 4[h 5th 6th Amt, Comm. Status Assignment or <br />Letter Action Adjustment Disp. Transfer Code <br />~ z] Date of Birth /Employer st <br />8 z] Reference sl <br />z <br />Reference <br />~x Reference aofleference ao <br />~_~ <br />9' <br />z] Note for Ne%t Monthly Collections Report <br />A• z] PS 2s z7 CBR 3n 71 DMVR 34 3s AC 7s <br />Form ac-7e-o4 • Link ~I,9 and Ais for Central Collection Use Only <br />eo <br />L ~ <br />