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Sent: Wednesday, April 13, 2 0:21 AM <br />To: reversals <br />Subject: OPC Reversal Request - 04/13/2011, Receipt A53989, CAOTRSanioaEH <br />Official Payments Corp.,- Reversal 1 Refund Request 11 <br />Telephone: 866-352-5002 Please Fax Signed Form To: 334-321-4669 <br />Client Action Required <br />Approval Signature - Please Sign and Date Here: <br />Billing Option for Reversal - Please Select One: MACH Debit, or () Invoice <br />ACH Debit/Invoice Amount - Please Enter the Amount: i ,-3&(, . —' ($366.00) <br />Original Transaction Information 1-7 <br />Transaction Date/Time: 04/11/2011 12:58:36pm <br />Amount Before Fee: 366.00 <br />Fee' <br />Payment Channel: Internet <br />C Fee: 10.95 <br />Payment T <br />y Type: Environmental Health Fees <br />Total 376.95 <br />Account Number: 556752******7582 <br />Pa ent R eipt: A53989 <br />Auth, Type: Credit Card: Normal Auth <br />Fee R c pt: A53 <br />Account Type: MasterCard. <br />Prim Id ntifie • co 2133 2908 Benjamin Holt Drive <br />Stockton Ca. 95207 <br />Rev real efu <br />RequestedAry <br />Client <br />+/Customer <br />Name: Laurie Brown <br />yame:Phone: <br />209-468-3447 <br />one: <br />Fax; Z•d 9 (o ` D / 8 <br />Address: <br />Email: °lbrown(Msjcehd.com <br />City: State: <br />R ersal / Refund Information <br />Payment Amount to be Reversed: 366.00 OPC Fee Amount to be Reversed: 10.95 <br />Reversal Reason: Oth Reversal Initiator: Client <br />Request Submitted By: fir1lllips (extension 866- Request Submission Date: 04/13/2011 <br />352-5002) <br />Explanation: Per client; paid in error <br />Official Payments Use Only <br />For Posting Only: Yes / No <br />Reversal Processed By: ACH Processed By: <br />Date:-. Date: <br />