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�'EQ ESTED &Y <br />EXT. <br />DEPARTMENT <br />-1 V71� 7 <br />AU rH. FOR CHECK DELIVERY <br />J <br />NCO -4871 DAL-kl 1 -8-4 <br />t <br />PAY TO- oil <br />NEW VENDOR/PAYEE fAX IDENTIFICATION NUMBER <br />RL2 am <br />34 1; <br />F - <br />prc, <br />ADDRESS: C, <br />EMPLOYERID NO. F 77 <br />=E <br />c <br />OR <br />X <br />REOUEST <br />SOCIAL SECURITY Fj <br />NUMBER <br />DELIVER TO: F- <br />(AUTHORIZATION <br />VENDOR/PAYEE <br />REqUIRED) -41YI <br />1099 REPORTABLE DYES Llwol. <br />WRITTEN tfA <br />AMOUNf--- "'L-VOLLARS //TCENTS <br />�'EQ ESTED &Y <br />EXT. <br />DEPARTMENT <br />(CO -197 DISBURSEMENT AP7VAL) <br />AU rH. FOR CHECK DELIVERY <br />RECEIVED CASH AMOUNT <br />RL2 am <br />34 1; <br />prc, <br />REOUEST <br />VENDOR/PAYEE <br />0 <br />REQUEST NUMBER <br />SUBMIT- <br />DATE PAYMENT DUE <br />Lu <br />AMOUNT TO BE PAID <br />TR <br />D <br />A D <br />TING <br />.... <br />P� <br />uj <br />(A <br />CL <br />Lu <br />...... <br />ID <br />NUMBER <br />RESS <br />UNIT <br />MO JDAY <br />YR MO I DAY <br />YR <br />u, <br />1- 2 <br />12 <br />22123-25 <br />126 <br />-37 38-41 <br />......... . . . . . <br />57 <br />159 <br />61 63 165 <br />67 <br />1 <br />82 <br />83 <br />84 <br />85 <br />86 <br />108- <br />—120 <br />13 <br />40 <br />�E' <br />oo(b16z47ro <br />�01 <br />RE <br />0040765248 <br />Ix q <br />X. <br />...... . . . . . <br />PREPAID ITEMS 109911042 DATA <br />BANK -- I PAYABLESUSEONLY <br />CODE CHECK NUMBER -- DATE AMOUNTFOR <br />REPORTING <br />MO IDAY JYR <br />45-48 19-54 55 57 59 71 77 —87 <br />MESSAGE: ENTER PRE -CODED MESSAGE CODE IN COL. 45-47, ANDIOR ENTER FREE FORM MESSAGE IN COL. 48-120. <br />CODE LINE 1 <br />6-47 48 92:93 <br />r -6,e .4 <br />OTHER ACCOUNT DISTRIBUTION <br />ACCT. FUNC. LOCATION <br />CODE SUB. ETC. <br />cc ACCT. 5 1 6 1 7 1 8 1 9 1 10 11 1 12 1 13 <br />�2 44 145-48 �9-51 �2-56 57 159 161 163 165 1-67 69 171 173 175- <br />-- <br />50 <br />V -Z�� <br />LINE 2 <br />;; 2E <br />AMOUNT sz <br />cto <br />92 102 112 113 <br />DATE <br />