Laserfiche WebLink
CASH OR CHECK REQUEST NCO-4871 DAL 01.83) <br /> PAY TO: `--) �' ( Irl i_ J 1 NEW VENDOR/PAYEE TAX IDENTIFICATION NUMBER <br /> N\j I G'(-I rri i% f rte. �i ( 1; 1 V <br /> ADDRESS: Il it Z , n (-'I V EMPLOYER ID NO. � 1 <br /> OR <br /> SOCIAL SECURITY m 2 <br /> NUMBER { <br /> DELIVER TO: <br /> (AUTHORIZATION <br /> REQUIRED) <br /> 1099 REPORTABLE YES YNO <br /> A'i/ �* WRITTEN �- <br /> - AMOUNT7�(� �\f f1�(�; DOLLARS �"--- CENTS <br /> REQUESTED BY EXT l l ) DEPARTMENT ICC 197 DISBURSEMENT APPROVAL) AU fH FOR CHECK DELIVERY RECEIVED CASH AMOUNT DATE <br /> REQUEST <br /> VENDOR/PAYEE REQUEST NUMBER cj a O x ... <br /> SUBMIT- DATE PAYMENT DUE �j a y AMOUNT TO BE PAID <br /> TR CL <br /> ID NUMBER ADD UIN T :: MO DAY YR MO DAY YR ~ a NG Lu a ` W �`�. <br /> RESS :. ¢ U7 N a D Y) :::: <br /> 1- 2 12 13 --- - 22 23-25 126 37 38 41 57 59 61 63 65 67 1 82 83 84 85 6 108 <br /> ao 00o RE 074!083454 Lys €`` ,7 3 a0�� I7 8g ``> LSO: <br /> J PREPAID ITEMS 109911042 DATA PAYABLES USE ONLY <br /> w TR BANK <br /> CODE CHECK NUMBER DATE '? o CAT STATE AMOUNT FOR <br /> CNTRY REPORTING <br /> F MO DAY YR Z <br /> Z <br /> W t- -2 i 4548 9 54 55 57 59 ?i' 71 72 7476 77 87 <br /> f <br /> Y <br /> L 43 <br /> I <br /> MESSAGE:ENTER PRE-CODED MESSAGE CODE IN COL.4547,AND/OR ENTER FREE FORM MESSAGE IN COL.48.120. <br /> TR I <br /> CODE LINE 1 I LINE 2 <br /> I <br /> 1-2 i:ii:E 547 48 92'93 120 <br /> II I/ <br /> 45 L A (1 C� ( Cts `�. ' /\ t4 K_ e? <br /> OTHER ACCOUNT DISTRIBUTION <br /> ' <br /> iG �jQ ACCT. SUBLOCATION o <br /> AMOUNT w_ <br /> Z TR ¢H w .CODE ETC. FV <br /> O 'A 1n ¢ ACCT. 5 6 7 8 9 10 11 12 13 <br /> 1 2 `'? 2 44 4548 9-51 2 56 57 59 61 63 65 67 69 71 73 75 92 102 112 113 <br /> H50 c r) <br /> F3 50 <br /> W 50 I I I <br /> a <br /> '56- <br /> 5 0 <br /> • PAYEE COPY , <br />