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MISCELLANEOUS BILLING REQUEST FORM <br /> ORIGINATOR'S NAME /EW# Lowen/ 2294 EXT 7443 DATE 7/11/2013 <br /> NEW ACCOUNT SETUP ❑ ADJUSTMENTS & CHARGES <br /> ACCOUNT SETUP <br /> CUSTOMER INFORMATION <br /> CUSTOMER NAME City of Eugene <br /> PRESMISES /PROPERTY ADDRESS <br /> MAILING ADDRESS <br /> CONTACT NAME <br /> BUSINESS PHONE# / CELL# <br /> FAX NUMBER <br /> SSN OR TIN /EIN# ` <br /> REFERENCE INFORMATION `?✓� ^ <br /> FULL LEGAL NAME, RELATIONSHIP A I / <br /> COMPLETE ADDRESS \ / � PH ONE(HOME, BUSINESS,CELL) , BUSINESS INFORMATION <br /> TYPE OF BUSINESS (COPR, LLC, ETC.) <br /> OWNERS LEGAL NAME & SSN <br /> ACCOUNTS PAYABLE <br /> PARTNERS (FULL LEGAL NAMES & SSN <br /> CORPORATION OFFICERS <br /> TITLE, FULL LEGAL NAME(S) <br /> ADDRESS <br /> PHONE (HOME, BUSINESS, CELL) <br /> BANK INFORMATION <br /> BANK NAME <br /> BRANCH (IE. MAIN BRANCH, EUGENE OR) <br /> AUTHORIZED PARTIES <br /> NOTES( CONTRACT #, J0B #, JOB SPECIFICS, ORDERED BY, ETC.) <br /> ADJUSTMENTS AND CHARGES <br /> RATE TO BE USED Decrease SLH1 - 7 ea AMOUNT TO BILL -$5.45 X 7 = -38.15 <br /> RATE TO BE USED Increase SLH7 - 7 eac AMOUNT TO BILL $4.40 X 7 $30.80 <br /> RATE TO BE USED Decrease SLH2 AMOUNT TO BILL -$8.20 <br /> ACCOUNT NUMBER 23736 -142 BUNCH CODE TO BE USED <br /> NOTES (REASON FOR ADJUSTMENT, ETC.) <br /> Per Jim Riggs @ COE repl (7) 100 W HPS S/L @ 4524 Souza (COE P #29642),2558 Souza (COE P #29645)3768 <br /> Peppertree(COE P# 29803)4532 Juhl St. (COE P #29575), 1545 28th (COE P# 26090)& Calistoga @Mondavi (COE P #97375) <br /> , Hilyard@ Pincrest (COE P# 27076 and Remove (1) 200 W HPS @ 150 W Broadway (COE P #9991) effective 7/08/2013 <br /> BILLING CONTROL USE ONLY <br /> DATE RECEIVED 7 -16 -13 DATE ENTERED 7 -16 -13 <br /> ENTERED BY EW2036 CYCLE NUMBER 01 <br /> ACCOUNT # 23736 -142 ADJUSTMENT # 100423970 <br /> • • <br />