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CPG # TO: ICE OF REVENUE AND RECOVERY co <br /> A=uvrr MMMITrnz ply ACCOUNT NO. DEPT.NO. REFERRAL <br /> 026000.0 nATP <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> ARBOR CONVALESCENT HOSPITALI 1 , 11 E 11 <br /> C/O NAME GUARANTOR SSN <br /> PLEASANT CARE CORP <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 900 N CHURCH ST LODI CA 95240 209.333-1222 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1111 W ROBINHOOD STOCKTON CA 95207 209-956-9M <br /> USER REFERENCE NO. I BILLSTA CYCL14 STATUS DATE BMC C INT MONTHLY PAY AMT <br /> 1216 HAZMAT —iLL A I I I 1 2/23/05 <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NOINARRATIVE <br /> SON=DATE: DATE OF <br /> STAR'` STOP MED REC NO CHARGE <br /> O'ARGEDEPT.NO. DESCRIPTION AMOUNT AGE DEPT.NO. DESCRIPTION AMOUNT <br /> 230 026000.0 2005 10%Late Charge $27.00 <br /> TOTAL $27.00 <br /> DOS DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ARBOR CONVALESCENT HOSPITAL 209-333-1222 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 900 N CHURCH ST L ODI CA 95240 <br /> Oregon co- <br /> LAST FIRST MI nrLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> ARBOR CONVALESCENT HOSPITAL 209-333-1222 <br /> ==N <br /> STREET CITY ST ZIP CODE <br /> IRCH ST LODI CA 95240 <br /> H CKED Y DATE Z� �S oa, 20 <br />