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MISCELLANEOUS BILLING REQUEST FORM <br /> ORIGINATOR'S NAME /EW# JENKINS /EW2442 EXT 7117 DATE 6/29/2013 <br /> NEW ACCOUNT SETUP ❑ ADJUSTMENTS & CHARGES X <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 # CG/1 <br /> FAX NUMBER <br /> SSN OR TIN/EIN# C9 ri REFERENCE INFORMATION <br /> FULL LEGAL NAME, RELATIONSHIP <br /> COMPLETE ADDRESS A�MIVI�� I_ <br /> PHONE(HOME, BUSINESS,CELL) <br /> BUSINESS INFORMATION <br /> TYPE OF BUSINESS (COPR, LLC, ETC.) • \-/2 <br /> OWNERS LEGAL NAME & SSN <br /> ACCOUNTS PAYABLE <br /> (:11\114i\-)31\ 9-Q-D <br /> PARTNERS (FULL LEGAL NAMES & SSN 1 ' > ^� <br /> CORPORATION OFFICERS f Y / <br /> TITLE, FULL LEGAL NAME(S) 1� <br /> ADDRESS l <br /> PHONE (HOME, BUSINESS, CELL) <br /> BANK INFORMATION <br /> BANK NAME <br /> BRANCH (IE. MAIN BRANCH, EUGENE OR) <br /> AUTHORIZED PARTIES <br /> NOTES (CONTRACT #, JOB #, JOB SP' CIFICS, ORDERED BY, ETC.) <br /> ADJUSTMENTS AND CH • GES <br /> RATE TO BE USED SLH7 /ADD AMOUNT TO BILL 4.15 X 17 = 70.55 /MONTH <br /> RATE TO BE USED AMOUNT TO BILL <br /> RATE TO BE USED AMOUNT TO BILL <br /> ACCOUNT NUMB ' 23736 -142 BUNCH CODE TO BE USED <br /> NOTES (REASO FOR ADJUSTMENT, ETC.) <br /> CON •' 70w hps PER Dwg d- 26811, CITY GJN #4487 — TIMBERLINE HILLS #2 EFFECTIVE 1/4/2013. Please bill for <br /> otal 493.85 70.55 x 7 for January through July 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 /> • • <br />