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� ) //Z � >� <br /> TO: OFFICE OF THE COLLEC' / <br /> CPG # - 4 39) <br /> ACCOUNT TRANSMITTAL` / <br /> I <br /> ACCOUNT NO. F DEPT. NO. .DAT <br /> -FQ41 0 1 ., 04 1:3 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> /jNQBIERG DOROTHY <br /> C/O NAME GUARANTOR SSN <br /> 1 1 1 1 1 1 1 <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO.4 t9 <br /> 1901 IEtY emiltip 1#79n ec <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> USER REFERENCE NO. I BILLSTA CLE STATUS D4TE M M INT MONTHLY PAY AMT PYMT PROB <br /> DUE DATE TERM GATE <br /> qGTaqkl I I ILI I I I I Ii <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECMOPRENT USER REFERENCE NO/NARRATIVE <br /> I I I I <br /> SERVICE DATE: DATE OF DBA: Linden Medical Clinic Inc. ; 4950 N. Bonham, Linden, <br /> START STOP MED REC NO CHARGE CA <br /> 1111 Jill I <br /> HNRDG DESCRIPTION AMOUNT HNDGE DEPT NO DESCRIPTION <br /> 380 1OpC11 UGST Fees();I ,u , 1 11?4p 1091 1 1 1 1 t I I <br /> 189 Q4jOp 1, Surcharge < atc 24 0 <br /> 1 1 1 1 1 1 1 <br /> TOTAL 1564 00 <br /> GUARANTOR <br /> DOB OR LIC NO AUTO LIC NO 3/'/�3 _ BSL <br /> �/S alb <br /> PRIOR STREET Yf7 aII CITY ST ZIP CODE <br /> 'r' '40<6�8' <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> 1 1 1 1 1 1 I I I I I I I I I I I I <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> I I I I I I I I I I I I I I I I I I I I I 1 1 1 1 1 1 1 I I I I I I I <br /> SPOUSE <br /> LAST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> AE1P,LAFtLEb BY CHECKED BY � q' �/ ATE <br /> � � 2' � ® COL. p 13/851 <br />